COVID‐19 PANDEMIC ‐ PATIENT DISCLOSURES
We are required by law to screen all non-employee visitors to our dental practice. 
We appreciate your patience and understanding. 


Thank you for coming in to our office today.  In light of the COVID-19 virus, please help us better care for you and our entire dental community by reading and responding to the following.
 
Risk factors: A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, and any other disease or medical condition) can put you at greater risk for contracting COVID‐19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment to protect you.
 



Do you have a fever or above normal temperature?


Have you experienced shortness of breath or had trouble breathing?


Do you have a dry cough?


Do you have a runny nose?


Have you recently lost or had a reduction in your sense of smell?


Do you have a sore throat?


Have you tested positive for COVID‐19?


Have you been tested for COVID‐19 and are awaiting results?
 
 
Have you been diagnosed with COVID-19 by a licensed healthcare provider (doctor, nurse, physicians's assistant, etc.) in the past 10 days?

 
 
Have you been told that you are suspected to have COVID-19 by a licensed healthcare provider in the past 10 days?
 
 
I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.
 
I agree to notify Dr. Calender at 817-442-8282 if I develop COVID-19 symptoms within 2 days of my dental visit.


Rev. 7-2021