Happy Tooth COVID Questionnaire and Consent Form
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 currently have any of the symptoms of COVID-19 that include fever, headaches, cough, shortness of breath, loss of smell and taste?

Have you been in contact with someone who has tested positive for
Have you or someone in your household tested positive for COVID‐19 within the last 10 days?
Have you traveled outside the United States in 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 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.

I knowingly and willingly consent to have elective (non-emergency) dental treatment completed during the COVID-19 pandemic.

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing. Dental procedures create water spray which is how the disease is spread. The ultra-fine nature of the spray can create aerosols and linger in the air for minutes to sometimes hours, which can transmit the COVID-19 virus and how the disease can spread.

I understand that due to the frequency of visits of other dental patients, the characteristics of the virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the virus simply by being in a dental office.

I confirm that I have read the notice above and know and understand that there is an increased risk of contracting COVID-19 virus in the dental office or with dental treatment. I further confirm that I am seeking treatment for non-emergency services. I understand and accept the additional risk of contracting COVID-19 from contact at this office. I also acknowledge that I could contract the COVID-19 virus from the outside this office unrelated to my visit here at Happy Tooth.

As a prerequisite to obtaining dental treatment proposed I acknowledge that I have been practicing all current CDC guidelines with respect to “social distancing” and have NOT been in contact with a person who had a positive test for COVID-19 or suspected to be positive.