New Patient Form

  • Dental Patient Screening Form

  • Date*
     - -
  • Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?*
  • Are you/they having shortness of breath or other difficulties breathing?*
  • Do you/they have a cough?*
  • Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*
  • Have you/they experienced recent loss of taste or smell?*
  • Are you/they in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.*
  • Is your/their age over 60?*
  • Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*
  • Have ypu/they traveled in the past 14 days to any regions affected by COVID-19 (as relevant to your location)*

  • Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective treatment.

  • COVID-19 PANDEMIC DENTAL TREATMENT NOTICE AND ACKNOWLEDGEMENT OF RISK

  • The Word Health Organization has characterized the COVID-19 virus, also known as "Coronavirus," as a pandemic. Our practice wants to ensure you are aware of the risks of exposure to COVID-19 associated with receiving treatment during this pandemic.

    COVID-19 is highly contagious and has a long incubation peroid. You or your healthcare providers may have the virus, not show symptoms and yet still be highly contagious.COVID-19 can reult in a life0threatening respiratory disease in some patient(s). You may be exposed to COVID-19 at any time or in any place. Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office.

    Dental procedures can create fine water spray or "aerosols" which may remain in the air for several minutes to hours. These aerosols may contain the COVID-19 virus and may create a risk of COVID-19 exposures. You cannot wear a procetice mask over your mouth to reduce exposure during treatment as your healthcare providers need access to your mouth to render care. This leaves you vulnerable to COVID-19 transmission while receiving dental treatment.

    To provide a save environment for out patients and staff, this practice follows the applicable state and federal regulations and protocols for infection control, universal personal procetion, and disinfection. However, due to the nature of the procedures we provide, it may not be possible to maintain social distancing between patients, doctors, and staff at all times.

    Patient Acknowledgement

    I acknowledge that I have read the Notice above that I understand and accept that there is an increased risk of COVID-19 esposure with treatment during the pandemic.

    I understand and accept the increased risk of COVID-19 exposures with treatment at this off ice.

    I also acknowledge that I could, or may have exposure to COVID-19 from outside this office and unrelated to my visit here.

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