COVID-19 Patient Notice & Acknowledgment Form

As you are aware, the Centers for Disease Control and Prevention has issued warnings and precautions to health care providers worldwide regarding coronavirus and COVID-19.

Here at Joel D. Singer, DMD we are taking every precaution to limit the exposure to any virus within our office community and we ask that you participate in the taking these precautions.

Please inform us immediately if you are currently experiencing a fever, cough, or difficulty breathing. By checking this box, you attest that you do not currently have a fever, cough, or difficulty breathing.

Please inform us if you have had any contact or other exposure to a person diagnosed with, or subsequently diagnosed with, COVID-19. By checking this box, you attest that you have not had any contact or other exposure to a person diagnosed with, or subsequently diagnosed, with COVID-19.

Please inform us immediately if you have traveled outside of the United States within the past thirty (30) days. By checking this box, you attest that you have not traveled outside the United States within the past thirty (30) days.

Please inform us immediately if you have had any recent travel outside of the state of New Jersey. By checking this box, you attest that you have not traveled outside the state of New Jersey within the past thirty (30) days.

If you have traveled outside of this state, please list all of the locations to which you have traveled in the last 30 days:

In our efforts to protect the safety of the practice community as well as the community at large, it is the policy of Joel D. Singer, DMD to reschedule a patient’s appointment for elective care if the patient is exhibiting symptoms of COVID-19, recently traveled abroad or to a high risk area, or was subject to a known exposure event.

In placing your signature below, you attest to the truth of your answers above and your understanding of Joel D. Singer, DMD office policy. We thank you and look forward to a return to normal practice.

Patient Name

Today's Date

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