Patient Advisory and Acknowledgement

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

Dear Parent,

You and your family 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 team, other patients, and your family, please be truthful and candid in your answers.

Have you, your child(ren) or anyone in the house hold experienced any of the following signs or symptoms in the past 14 days:

Fever or above normal temperature?*

Yes
No

Shortness of breath or trouble breathing?*

Yes
No

Dry cough?*

Yes
No

Runny nose?*

Yes
No

Recent loss or a reduction in their sense of smell?*

Yes
No

Sore throat?*

Yes
No

Headache, fatigue or GI upset?*

Yes
No

In contact with someone who has tested positive for COVID‐19?*

Yes
No

Tested positive for COVID‐19?*

Yes
No

Tested for COVID‐19 and are awaiting results?*

Yes
No

Traveled outside the United States by air or cruise ship in the past 14 days?*

Yes
No

Traveled within the United States by air, bus or train within the past 14 days?*

Yes
No

By signing this document, I acknowledge the answers I have provided above are true and accurate. Additionally, I knowingly and willingly consent to have emergency dental treatment completed on child during COVID-19 pandemic.

Child/Children of the practice*

Parent Signature*

Date*

Printed Name*

Patient Advisory and Acknowledgement Form