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Patient Advisory and Acknowledgment Receiving Dental Treatment During the COVID-19 Pandemic

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.

 
 
Do you have any flu or Covid-19  symptoms?


Have you tested positive for COVID‐19?
 
 
Have you been in contact with someone who has tested positive for
COVID‐19 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.

Signature Pad

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