Form

COVID-19 Screening Form and Release

I consent for myself/the patient to receive treatment from Dr Elona Gaball and associates at Inspire Smiles (Practice) during the COVID-19 outbreak. While I understand that Inspire Smiles is continuously reviewing and implementing recommendations to ensure the safest possible environment, I understand that no environment is totally risk free.

I understand there is much to learn about the newly emerged COVID-19, including how it spreads and is transmitted.

I understand that, based on what is currently known about COVID-19, the spread is thought to occur mostly from person-to-person via respiratory droplets during close contacts. I understand that close contact can occur from being within approximately 6 feet of someone with COVID-19 for a period of time, or by having direct contact with infectious secretions from someone with COVID-19.

I understand that carriers of COVID-19 may not show symptoms but may still be contagious.

I understand that I or the patient may have some risk of contracting the virus by being in, and by receiving treatment at, the Practice. However, I believe my being seen at the Practice is worth that risk.

COVID-19 Screening Questions:

Do you have a fever or above-normal temperature (>100.4° F)?
Are you experiencing shortness of breath or having 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 or taste?
Do you have a sore throat?
Are you experiencing chills or repeated shaking with chills?
Do you have unexplained muscle pain?
Do you have a headache?
Even if you don’t currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?
Have you been in unprotected contact with someone who has tested positive for COVID-19 in the last 14 days? “Unprotected contact” means without the use of personal protective equipment.
Have you traveled more than 100 miles from your home in the last 14 days?
Have you been tested for COVID-19 in the last 14 days?

Please Check one of these boxes:

If you answered "yes" to any of the Screening Questions, please explain

Release of Claims

I and the patient release, that is, I/we give up and forever relinquish any and all claims, complaints and any legal actions against Elona Gaball DDS Inc, Inspire Smiles, its/their owner(s), providers, or other associates related to becoming infected by, or a carrier of, COVID-19 and any consequences thereof including any injury of any kind to myself or others.

I acknowledge that I have read and understand this Release and that I knowingly and voluntarily have signed it.

First Name

Last Name

Date Of Birth

Patient/Legal Guardian Signature

Date