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This patient disclosure form seeks information from you that we must consider before making decisions in the circumstance of the COVID-19 virus.

I knowingly & willingly consent to have dental treatment completed during the COVID-19 Pandemic. I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. It is impossible to determine who has it and who does not; given the current limits in virus testing. Dental procedures produce aerosols. Standard precautions reduce risk as much as possible, but this is how the virus could be spread.

A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment radiation, chemotherapy and any prior or current disease or medical condition), can put you at greater risk for contracting COVID-19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us.

It is also important that you disclose to this office any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus. If you have been exposed or could potentially be a carrier, please stay home and call us to reschedule your appointment.

Do you have a temperature 100.0 or greater?
YesNo

Have you experienced shortness of breath or had trouble breathing?
YesNo

Do you have a dry cough?
YesNo

Have you recently had a loss or reduction in taste or smell?
YesNo

Do you have a sore throat?
YesNo

Have you been in contact with someone who has tested positive for COVID-19?
YesNo

Have you tested positive for COVID-19?
YesNo

Have you been tested for COVID-19 and are awaiting results?
YesNo

Have you traveled outside the United States by air or cruise ship in the past 14 days?
YesNo

Have you traveled within the United States by air, bus or train within the past 14 days?
YesNo

I understand that due to frequency of visits of other dental patients, the characteristics of the virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the virus simply by being in a dental office.

I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. And the CDC recommends social distancing of at least 6 feet for a period of 14 days to anyone who has, and this is not possible with dentistry.

I understand that I will contact the office (and my Primary Care Physician) if I develop any COVID-19 symptoms within the next 14 days.

Please record your temperature at home below.

Date recorded:

I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.