OperaDDS - Form

COVID PANDEMIC ‐ PATIENT DISCLOSURES

*MASKS ARE STILL REQUIRED IN ALL HEALTHCARE/DENTAL OFFICES IN MA PER ORDER OF THE GOVERNOR"S OFFICE*

Patient First Name

Patient Last Name

Patient Date Of Birth

PLEASE IMMEDIATELY REVIEW THE FOLLOWING FORM. If any answer is "yes", please contact us immediately.

PLEASE COMPLETE AND SUBMIT THIS FORM WITHIN 48 HOURS PRIOR TO YOUR APPOINTMENT. Upon submitting, your information will be sent securely back to our office.

This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID virus.

It is also important that you disclose to this office any indication of having been exposed to COVID, or whether you have experienced any signs or symptoms associated with the COVID virus.

Have you tested positive for COVID in the last 10 days?

Have you been in close contact (unmasked, less than 6 feet apart for > 15 minutes) to anyone who has tested positive for COVID in the last 10 days?

Is there anyone living in your home who has tested positive for COVID in the last 30 days?

Are you experiencing any COVID-like symptoms at this time (cough, runny nose, fever, loss of taste or smell)?

If you answered "Yes" to any of the above questions, please explain in the box below, and call our office as soon as possible.

*Upon arrival to the office parking lot, please wait in your vehicle.

*Call the office at 413-587-0888, to let us know you are here.

*When you get the okay to come in, please wear a mask. *Masks are still required in Healthcare and Dental Offices in Massachusetts per order of the Governor's office.

*Companions must wait outside.

*A PPE fee, Code 1999, will be submitted to all insurance companies, and no additional cost will be incurred to you as the patient.

*PLEASE CONTACT OUR OFFICE IF YOU TEST POSITIVE FOR COVID WITHIN 3 DAYS AFTER YOUR APPOINTMENT.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.

Patient/Legally Authorized Representative Signature Click button below to sign. Then click Save Signature. Then click Submit.

Date

Print Name Of Patient/ Parent or Guardian(if Minor)/Legally Authorized Representative

Relationship If Signed On Behalf Of Patient