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COVID‐19 PANDEMIC ‐ PATIENT DISCLOSURES

I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious.

There are several modes of transmission of COVID-19 which could be present in a dental office. We are following the ADA and CDC guidelines to minimize the risk of transmission.

This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID‐19 virus.

I understand that due to the frequency of visits of other dental patients, the characteristics of the virus, and the characteristics of dental prodecures, that I have an elevated risk of contracting the virus simply by being in a dental office.

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?

Do you have a sore throat?

Have you been in contact with someone who has tested positive for
COVID‐19 in the last 14 days?

Have you tested positive for COVID‐19?

If you have tested postitive for COVID-19, what was the day of your test?

Have you been tested for COVID‐19 and are awaiting results?

Have you traveled outside the United States by air or cruise ship in
the past 14 days?

If you have traveled, where did you travel to?

Have you traveled within the United States by air, bus or train within
the past 14 days?

If you have traveled, where did you travel to?

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.

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