Consent and Triage for Covid-19

Patient Advisory and Acknowledgement-Receiving Dental Treatment During COVID-19

Dear Patient,

While our office complies with the State Health Department and 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 symptoms-free and, to the best of our 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 even 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 Name

Date

PLEASE ANSWER “YES” OR “NO” TO THE FOLLOWING QUESTIONS:

HAVE YOU HAD OR IS DIAGNOSED WITH COVID-19?
Yes
No
ARE YOU CURRENTLY WAITING THE RESULTS OF A COVID-19 TEST?
Yes
No
DO YOU HAVE A FEVER?
Yes
No
DO YOU HAVE ANY SHORTNESS OF BREATH?
Yes
No
DO YOU HAVE A DRY COUGH?
Yes
No
DO YOU HAVE A RUNNY NOSE?
Yes
No
DO YOU HAVE A SORE THROAT?
Yes
No
DO YOU HAVE SNEEZING, WATERY EYES, AND /OR SINUS PAIN/PRESSURE THAT IS UNUSUAL AND NOT RELATED TO SEASONAL ALLERGIES?
Yes
No
HAVE YOU EXPERIENCED HEADACHES, FATIGUES OR WEAKNESS?
Yes
No
HAVE YOU LOST YOUR SENSE OF TASTE AND/OR SMELL?
Yes
No
WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELED TO ANY FOREIGN COUNTRY?
Yes
No
WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELED WITHIN UNITED STATES?
Yes
No
IF SO, WHERE?


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