*MASKS ARE REQUIRED IN OUR OFFICE*
Although the statewide mask order will be lifted March 10th, we are following the CDC's recommended guidelines and will still require ALL patients and staff to continue to wear a mask before entering our office.
We understand the concern surrounding COVID-19. Nothing is more important than the health and safety of both our patients and team members. We have many patients who have not yet received the vaccine or may be unable to do so, therefore we require all patients to keep wearing a mask while in our office. We are taking precautionary steps to make our public space and treatment rooms as safe as possible.
Please assist us in our effort by doing a few simple things:
1.Please call and allow us to reschedule your appointment if you have tested positive for COVID-19 or are awaiting test results, have come in contact with a known COVID-19 postive person, have any COIVD-19 symptoms listed below, or are experiencing significant allergy symptoms inlcluding an uncontrolled cough. COVID-19 symptoms can include: fever, shortness of breath, loss of taste or smell, dry cough, fatique, headache, body aches or chills, nausea, vomiting, stomach upset, diarrhea, runny or stuffy nose, rash on feet or toes, oral rash, or general feeling of maliase. If any of the above condiitons apply to you, please allow us to reschedule your appointment.
2.Wear a well-fitting mask prior to entering our office, make sure the mask covers both your nose and mouth, and keep the mask in place unless actively receiving treatment. Due to limited supplies, masks can not be provided.
3.Keep social distancing (6 feet) as much as possible while in the office.
4.Brush and floss your teeth at home just prior to coming into your appointment.
This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID‐19 virus.
A weak or compromised immune system (including, but not limited to, conditions such as diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, heart disease, lung disease, kidney disease, autoimmune disorder, history of smoking or vaping, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID‐19. In addition, persons over 60 years old, pregnant women, and infants may be at higher risk. Please disclose to us any condition that compromises your immune system and please understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us.
I fully understand and acknowledge the above information, risks, and cautions regarding COVID-19. I acknowledge by signing this form that I understand that all reasonable protective measures to prevent the spread of COVID-19 are being implemented in the office, however, because the office is a place of public accommodation, the risk of COVID-19 is still present. I willingly choose to have my dental treatment in this environment and assume all risks associated with doing so.