Wellness Questionnaire Avila Dental

Dear Avila Dental family, thank you for your support and patience in the past weeks as our office has been closed in compliance with our Governor's directives during the peak of the COVID-19 pandemic. We are very much looking forward to resuming dental care in the safest possible way for both patients and staff. Part of that initiative includes the attached Wellness Screaning and Treatment Consent that we request is returned prior to EACH APPOINTMENT. Please call or email the office is you have any questions. Looking forward to seeing you soon!

Name

First nameLast name

In the last 14 days, has the patient (or any member of the household) had any of the following?

Has the patient (or any of the household) had any of the following occur?

Diagnosis of COVID-19 infectionWaiting on results of test fo COVID-19 infectionSymptomatic but unable to get tested for COVID-19None to all

If the answer to any of these questions changes before the appointment, I agree to notify Avila Dental as soon as possible. Also, if the answer is yes to any of the previous questions, I understand I might be asked to reschedule the appointment.

Yes, I understand

Treatment consent: Please be assured that our office has always met or exceeded the requirements set forth for sterilization and infection control from the CDC and OSHA, and will continue to do so. However, it is possible to contract COVID-19 infection (or any other communicable disease) in any public space. Our office will provide for socially distant appointment scheduling, and also has added a number of new technologies and techniques to the practice to enhance our level of safety. Re-entering public life comes with some risks that we all must weight, however we want you to feel confident that our office is taking every step to keep everyone safe during this time. By clicking "yes" below indicates that the risks involved are accepted, and that consent is given for treatment to be provided by the office of Veronica Bello DDS MSD.

Yes, I consent to dental treatment

Sign

Clear

Wellness Screening and Treatment Consent