Patient Advisory and Acknowledgment

Dear Patient:

You have presented to the office today because you have an urgent dental condition which must be treated at this time and cannot be postponed until the current COVID-19 risk period abates. Please be advised of the following:

While our office complies with 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 below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.

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/RESPONSIBLE PARTY:

DATE:

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

ARE YOU CURRENTLY AWAITING THE RESULTS OF A COVID-19 TEST?

YES NO

DO YOU HAVE A FEVER?

YES NO

DO YOU HAVE ANY SHORTNESS OF BREATH?

YES NO

DO YOU HAVE A DRY COUGH?

YES NO

DO YOU HAVE A RUNNY NOSE?

YES NO

DO YOU HAVE A SORE THROAT?

YES NO

DO YOU HAVE SNEEZING, WATERY EYES, AND/OR SINUS PAIN/PRESSURE THAT IS UNUSUAL AND NOT RELATED TO SEASONAL ALLERGIES?

YES NO

HAVE YOU EXPERIENCED HEADACHES, FATIGUE, OR WEAKNESS?

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

WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELLED WITHIN THE UNITED STATES?

YES NO

IF SO, WHERE?

HAVE YOU BEEN FULLY VACCINATED FOR COVID-19?

YES NO

IF YES, PLEASE PROVIDE DATE OF VACCINATION.

Name:

Signature:

Date:

Your information will be encrypted.