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:

PLEASE ANSWER “YES” OR “NO” WITH YOUR INITIALS, TO THE FOLLOWING QUESTIONS:

Have you been vaccinated for COVID-19?

Yes No

If yes, Date of Vaccination

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

Do you have a fever in the last 72 hours?

Yes No

Do you have any unusual shortness of breath?

Yes No

Do you have a dry cough, runny nose, and/or sore throat?

Yes No

Are you experiencing headaches, fatigue, and/or weakness that is unusual?

Yes No

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

Yes No

Within the last 14 days, have you travelled to any Foreign Country?

Yes No

If not vaccinated, have you traveled Domestically in the last 10 days?

Yes No

If yes, Date of Return home

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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