Both COVID-19 forms to be completed on the day of your appointment

1 of 2: COVID-19 Consent Form

Thank you for trusting our practice. As with the transmission of any communicable disease, like a cold or the flu, you may be exposed to COVID-19, also known as “coronavirus,” at any time or in any place. 

We've always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit the transmission of all diseases in our office and we'll continue to do so.

 

Despite our careful attention to sterilization, disinfection, and use of personal barriers, there's still a chance that you could be exposed to an illness in our office, just as you might be at your grocery store or your favorite restaurant.

 

Nationwide social distancing practices have reduced the transmission of the coronavirus. Although we've taken measures to provide social distancing in our practice, due to the kind of treatment we provide, it's not possible to maintain social distancing between the dentist, dental staff, and sometimes other patients at all times.

Although exposure is unlikely, do you accept the risk and consent to treatment?*
Yes
No
Patient Name *
Parent/Guardian Name (if patient is under 18 years old)
Verification *

By checking this box, I confirm that the information given in this form is true.

I will also contact this office if I test positive for Covid-19 within 2 days after my appointment. 

Submit

2 of 2: COVID-19 Screening Form

If you have been exposed to a communicable disease prior to your dental appointment, you may spread the disease to the dentist, dental staff and to other patients/parents in the practice. Therefore, prior to each appointment, we require you to answer the following questions:

Have you, your child, or others accompanying you to today’s appointment been tested positive for or been diagnosed as having Covid-19?*
Yes
No
If so, when? Select date *
Do you, your child, or others accompanying you to today’s appointment have:*
A Fever (defined as above 99.6 degrees)
A Cough
Shortness of Breath and/or Trouble Breathing
Persistent pain, pressure or Tightness in the chest?
None

If any of you have any of these symptoms or have recently tested positive for or been diagnosed with Covid-19, you will be asked to reschedule your dental appointment.

Patient Name *
Parent/Guardian Name (if patient is under 18 years old)
Verification *

By checking this box, I confirm that the information given in this form is true.

Submit