Dear Patient: You have come to our office today for a routine dental evaluation and/or treatment that will be done during the COVID-19 pandemic. 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.

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 (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current 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 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 a fever or above normal temperature?
Have you or anyone in your household experienced shortness of breath or had trouble breathing?
Do you or anyone in your household  have a dry cough?
Do you or anyone in your household  have a runny nose?
Have you or anyone in your household recently lost or had a reduction in your sense of smell?
Do you or anyone in your household have a sore throat?
Have you or anyone in your household been in contact with someone who has tested positive for COVID‐19 in the past 14 days?
Have you or anyone in your household tested positive for COVID‐19?

Have you been tested for COVID‐19 and are awaiting results?
Have you been fully vaccinated against COVID 19? (People are considered fully vaccinated 2 weeks after their second dose of Pfizer or Moderna vaccines, or 2 weeks after a single-dose Johnson & Johnson's vaccine.)
Have you been informed by a school authority or a contact tracer that you have been in contact with someone with COVID 19 and that you need to self quarantine? 
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.