Patient Advisory and Acknowledgment

Dear Patient:

You have come to our office today for a routine dental evaluation and/or treatment that will be done during the COVID19 pandemic. Please be advised of the following:

While our office complies with the State Health Department and the Centers for Disease Control and Prevention Infection Control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees.
Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. 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 have asked you a number of “screening” questions bellow. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.

PATIENT/RESPONSIBLE PARTY:

DATE:

Have you been vaccinated for COVID-19?

Yes No

Have you, or anyone in your household, been diagnosed positive for COVID-19 in the last 14 days?

Yes No

Are you, or anyone in your household, currently awaiting results of a COVID-19 test?

Yes No

Have you, or anyone in your household, been exposed to someone who is diagnosed positive with COVID-19 in the last 10 days?

Yes No

Are you experiencing any flu like symptoms that are unusual for you?

Yes No

Have you lost your sense of taste and/or smell?

Yes No

Within the last 10 days, have you travelled to any Foreign Country?

Yes No

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.

Name / Signature:

Date:

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