Url Patient Advisory and AcknowledgmentReceiving Dental Treatment During the COVID-19 Pandemic Dear Patient: You have come to our office today for a routine dental evaluation and/or treatment that will be done during the COVID-19 pandemic. Please be advised of the following: While our office complies with State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees. Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge. In order to reduce the risk of spreading COVID-19, we have asked you a number of “screening” questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers. Patient/Responsible Party * Date * PLEASE ANSWER “YES” OR “NO” WITH YOUR INITIALS, TO THE FOLLOWING QUESTIONS: ARE YOU CURRENTLY AWAITING THE RESULTS OF A COVID-19 TEST? * YesNo INITIAL HERE * DO YOU HAVE A FEVER? * YesNo INITIAL HERE * DO YOU HAVE ANY SHORTNESS OF BREATH? * YesNo INITIAL HERE * DO YOU HAVE A DRY COUGH? * YesNo INITIAL HERE * DO YOU HAVE A RUNNY NOSE? * YesNo INITIAL HERE * DO YOU HAVE A SORE THROAT? * YesNo INITIAL HERE * DO YOU HAVE SNEEZING, WATERY EYES, AND/OR SINUS PAIN/PRESSURE THAT IS UNUSUAL AND NOT RELATED TO SEASONAL ALLERGIES? * YesNo INITIAL HERE * HAVE YOU EXPERIENCED HEADACHES, FATIGUE, OR WEAKNESS? * YesNo INITIAL HERE * HAVE YOU LOST YOUR SENSE OF TASTE AND/OR SMELL? * YesNo INITIAL HERE * WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELLED TO ANY FOREIGN COUNTRY? * YesNo INITIAL HERE * WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELLED WITHIN THE UNITED STATES? * YesNo IF SO, WHERE? INITIAL HERE *
