PATIENT/RESPONSIBLE PART Y DATE
ARE YOU CURRENTLY AWAITING 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 H AVE SNE E ZING, WATERY E Y E S, AN D/OR SINUS PAI N / PRE S S U R E
THAT IS UNUSUAL AND NOT RELATED TO SEASONAL ALLERGIES? YES NO
HAVE YOU EXPERIENCED HEADACHES, FATIGUE, OR WEAKNESS? YES NO
HAVE YOU LOST YOUR SENSE OF TASTE AND/OR SMELL? YES NO
WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELLED TO ANY FOREIGN COUNTRY? YES NO
WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELLED WITHIN THE UNITED STATES? YES NO
IF SO, WHERE?
PLEASE ANSWER “YES” OR “NO” WITH YOUR INITIALS, TO THE FOLLOWING QUESTIONS:
Patient Advisory and Acknowledgment
Receiving Dental Treatment During the COVID-19 Pandemic
Dear Patient:
You have come to our ofce 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 ofce 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.
