Please fill out "Patient Name, "Patient Age" and Answer the Pre-Screen questions: Check for YES


Screening Questions:
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo


Screening Questions:
YesNo
YesNo

• Any “yes” response for questions 1-7 must be discussed with the managing dentist immediately.

Please read the patient acknowledgement below.

I understand there is currently a health pandemic associated with COVID-19 and the novel coronavirus.

I understand public health authorities have recommended maintaining social distancing of a least 2 meters (6 feet) and I recognize it is not possible to maintain this distance while receiving dental treatment.

I understand that oral surgery/dental procedures can create water and/or blood spray, and that there may be an elevated risk of contracting and spreading the novel coronavirus in a dental office.

I confirm that I do NOT have any two or more or the following symptoms of COVID19: fever, new or worsening cough, sore throat, runny nose or headache, and that this is not currently a period where I am required to self-isolate for 14 days.

I confirm that I have not tested positive for COVID-19 and that I am not currently waiting for the results of a test for COVID-19.

I hereby consent to have dental treatment completed during the COVID-19 pandemic.

Signature of Patient: