Patient Advisory and Acknowledgment

Receiving Dental Treatment During the COVID-19 Pandemic

Dear Patient:

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.

PATIENT NAME

DATE

PLEASE ANSWER “YES” OR “NO” TO THE FOLLOWING QUESTIONS:

It is important that you disclose to the office any indication of having been exposed to COVID-19. PLEASE share whether you have experienced any signs or symptoms.

1. Have you tested positive for COIVD-19?

Yes

If yes, have you been cleared by your physician?

Yes

2. Have you been tested for COVID-19 and are awaiting results?

Yes

3. Have you had close contact with someone diagnosed with COVID-19 or with symptoms?

Yes

4. Have you traveled by plane, train, bus or cruise ship in the last 21 days?

Yes

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

Name Validation

Patient Advisory and Acknowledgment

Receiving Dental Treatment During the COVID-19 Pandemic

PLEASE ANSWER “YES” OR “NO” TO THE FOLLOWING QUESTIONS:

Signature