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COVID‐19 PANDEMIC ‐ PATIENT ADVISORY AND ACKNOWLEDGMENT

Dear Patient:

You are coming 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 canidid in your answers.

Do you have a fever or above normal temperature?

Have you experienced shortness of breath or had trouble breathing not related to asthma or other previously diagnosed condition?

Do you have a dry cough or runny nose not related to allergies?

Have you recently lost or had a reduction in your sense of smell or taste?

Do you have a sore throat?

Have you been in contact with someone who has tested positive for
COVID‐19 in the last 3 weeks?

Have you tested positive for COVID‐19 in the last 3 weeks?

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

Please explain YES answers:

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