Covid-19 Screening and Dental Treatment Consent Form

Please correct the errors described below.

Welcome to our office. We will do our best to make your appointments as convenient and as pleasant as possible. We ask that you please complete ALL paperwork so that we may better serve you. If at any time you have any questions, please feel free to ask any of our team members for help.

Patient Information (Confidential)

4. Do you currently have any of the following:


A. Fever (>100.4 °F), chills


B. Cough ( not due to allergies)


C. Difficulty breathing or shortness of breath


D. Recent loss of smell or taste


E. Do you have heart disease, lung disease, kidney disease,
Diabetes or any auto-immune disorders, 65 years or
older

If NO to “1-4(A-E), “ then you may schedule a for a routine dental appointment.
If YES to “E” only, you are at increased risk and should only schedule for emergency visit at this time.
If YES to “1-4(A-D)”, then you should NOT schedule an appointment and seek immediate medical attention.

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing. Neither LifeSmiles nor Dr. Parbhoo can guarantee my safety from exposure to the COVID-19 virus. I knowingly and willingly consent to have routine dental treatment completed during the COVID-19 pandemic.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

To be completed by a LifeSmiles of NewHope, PC Team Member only.

Current Vitals:

Your information will be encrypted.

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