COVID‐19 PATIENT SCREENING & DISCLOSURES

Office Protocols:

  • For 9:00 AM appointments, please do not come in the office until exactly 9:00 AM.
  • Masks are required for anyone over 2 yrs old
  • This screening form is required IN ADVANCE of entering the office at every appointment.
  • Only scheduled patients are allowed inside the office and ONE adult per family may accompany the patient(s).  If one adult is needed per child, then appointments must be made at different times.
  • DO NOT call or text when you arrive, just come in at your appointment time. Enter no more than 5 minutes early to limit time spent in the waiting room.
  • Once inside tempatures are taken and hand sanitizer is required before being seated.
  • Patients must have been in the D.M.V. area for at least 14 days before for all routine dental/orthodontic visits.
This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID‐19 virus.
 
A weak or compromised immune system 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 after discussing any such conditions with us.
 
It is also important that you disclose to this office any indication of having been exposed to COVID‐19, or whether you have experienced any signs or symptoms associated with the COVID‐19 virus.
 
 
 
Do you or anyone in your household have/had a fever within the past 14 days?
 
 
Have you or anyone in your household experienced shortness of breath or had trouble breathing within the last 14 days?
 
 
Have you or anyone in your household have/had a dry cough within the past 14 days?
 
 
Have you or anyone in your household have/had any flu like symptoms within the past 14 days?
 
 
Have you or anyone in your household recently lost or had a reduction in your sense of smell within the past 14 days?
 
 
Have you or anyone in your household have/had a sore throat within the last 14 days?
 
 
Have you or anyone in your household been in contact with someone who has tested positive for COVID‐19 in the last 30 days?
If so, enter date: 
  
 
 
Have you or anyone in your household tested positive for COVID‐19 in the last 30 days?
If so, enter date:
 
 
 
Have you or anyone in your household been tested for COVID‐19 and are awaiting results?
 
 
Have you or anyone in your household traveled outside or into the DC, Virginia, Maryland (DMV) area within the past 14 days?

 
Have you or anyone in your household traveled outside or into the United States the past 14 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 or my child's 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.