Patient Advisory and Acknowledgment: Receiving Dental Treatment During the COVID-19 Pandemic
You have presented to the office today because you have a dental condition which must be treated at this time and cannot be postponed until the current COVID-19 risk period abates.  Please be advised of the following:  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.
 

 
Have you been diagnosed positive for the COVID-19 virus at any time?
 
Are you currently awaiting the results of a COVID-19 test?
 
Do you have a fever?
 
Do you have any shortness of breath?
 
 Do you have a dry cough?
 
Do you have a runny nose?
 
Do you have a sore throat?
 
Do you have sneezing, watery eyes and/or sinus pain/pressure that is unusual and not related to seasonal allergies?
 
Have you experienced headaches, fatigue or weakness?
 
Have you lost your sense of taste and/or smell?
 
Have you traveled to any foreign country, or within the US, in the last 14 days?

Effective June 1, 2020 an office charge for infection control/personal protective equipment (PPE) of $10 will be applied to your bill/insurance claim.  This charge is the patient's responsibility if not covered by insurance.
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.