This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID‐19 virus. If the answer is YES to any of these questions, please understand that we may need you to cancel and reschedule treatment after a 14-day waiting period.
We thank you in advance for your understanding which allows us to uphold our safety standards and protect all our loved ones around us.

Do you have a cough?
Do you have a fever now or have you in the past week?

Are you experiencing shortness of breath or trouble breathing?

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

Have you experienced prolonged severe headaches within the last week?

Has a healthcare professional or government representative instructed you to self isolate in the past 14 days?
Have you been tested for COVID‐19 and received a positive result or are awaiting results? If yes, please provide further details:
Have you knowingly been in contact with anyone who has tested positive or is awaiting test results for COVID‐19? If yes, please provide further details:

Have you traveled in the last two weeks? If yes, where did you travel?
Have you received both doses of the COVID-19 vaccination? If yes, please provide the date you received the second vaccination.
By signing this document, I acknowledge that the answers I have provided above are true and accurate. Meyer Dental Group has implemented new safety procedures recommended by the American Dental Association (ADA), the U.S. Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA) to ensure our patients' safety and well being is not compromised, however I understand and acknowledge there are risks and cautions as it relates to treatment in a dental office.