COVID-19 Questionnaire

PATIENT ADVISORY AND ACKNOWLEDGMENTS

Receiving dental treatment during the Covid-19 pandemic

Dear Patient,

You have come to our office today for a routine dental evaluation and/or treatment that will be performed during the COVID-19 pandemic. Please be advised of the following.

While our office complies with the State Health Department, Center for Disease control, and infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees.

Our staff is symptom-free and to the best of our knowledge, has been practicing the recommended guidelines. However, since we are a place of public accommodation, other persons (including other patients) could be infected with or without their knowledge.

In order to reduce the risk of spreading COVID-19, we would like to ask you a few wellness and recent travel questions prior to your appointment /treatment.

For the safety of our staff, patients, and yourself, please be truthful and candid in your answers.

Patient Name

Date of Birth

In order to provide a safe environment for our patients and staff, we would like to ask you a few wellness questions prior to your appointment.

1) Have you been tested for COVID 19

Yes No

2) If yes, what was the outcome?

Positive Negative Results Pending

3) If positive has the infection resolved with a negative test.

Yes No I have not been tested after infection

4) Have you or anyone close to you experienced any of the following symptoms in the past 14 - 21 days?

Cough

Yes No

Shortness of Breath

Yes No

Difficulty breathing

Yes No

Fever

Yes No

Chills

Yes No

Muscle pain

Yes No

Sore Throat

Yes No

Recent loss of taste or smell

Yes No

Nausea

Yes No

Vomiting

Yes No

Diarrhea

Yes No

5) In the past 14 days have you been in contact with or taking care of anyone who has been diagnosed with COVID 19 and/or anyone with COVID + signs/symptoms.

Yes No

6) In the past 14 days have you travelled or been in contact with someone who has travelled domestically as well as internationally by commercial airline, train, or bus?

Yes No

7) In the past 14 days have you been in a public gathering of more than 10 persons.

Yes No

8) Have you been vaccinated

Not Vaccinated Partially Vaccinated Fully Vaccinated

9) Have you had booster shots?

Yes No

DENTAL TREATMENT CONSENT AND AFFIRMATION FORM COVID-19

1. I knowingly and willingly consent to dental treatment at 46 Dental P.C., by Dr. Yagnik and any designated associates or employees.

2. I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms yet are still highly contagious. It is impossible to determine who has COVID-19 and who does not given the current limitations and availability in COVID19 viral testing.

3. Risk of transmission: I understand that due to the frequency of visits of other dental patients under care, characteristics of the virus, and the characteristics of dental procedures, that I have risk of contracting the virus simply by being in a dental office, even though standard precautions are being observed.

4. I am unaware of being a possible carrier or infected: I confirm that I have not been tested positive for COVID-19 in the last 30 days and the information provided is correct to the best of my knowledge.

INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the risks of contracting COVID-19 from the dental office and dental procedures. I reaffirm that I am not a carrier of COVID-19 nor infected with COVID-19 to the best of my knowledge. I voluntarily assume any and all medical/dental risks, including the substantial and significant risk of serious harm, if any, which may be associated with any phase of my treatment as a result of the COVID19 pandemic. I acknowledge that the nature and purpose of the dental procedures recommended under the current circumstances and restrictions have been explained to me and that I have been given the opportunity to ask questions OR decline the procedure.

I acknowledge that I have read and understand these statements.

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.

Patient Name

Date

Patient's Signature

(MM/DD/YYYY)

Response Date

Your information will be encrypted.