Orthodontic Patient Advisory and Acknowledgment Receiving 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.

Appointment Instructions:

1. Please fill out the form below a day before your scheduled appointment.

2. Please text (909) 206-4321 on the day of your appointment to let us know you have arrived, but please wait in the car. Your car will be your virtual waiting room. When we are ready for you we will call you.

3. Please bring a face covering to wear when you come into the office. We are going to have everyone in the office use face coverings at all times and only remove during treatment or evaluation in the dental chair. Unfortunately, due to shortages in PPE, we cannot provide one for you.

4. We will be taking temperatures for all patients at their appointments, it may be a good idea to check at home the day of the appointment. If you have a temperature over 100.4 degrees F, we will have to reschedule your appointment for a different day.
Name of Patient *
Please confirm the cell phone number to best reach you. *
ARE YOU CURRENTLY AWAITING THE RESULTS OF A COVID-19 TEST? *
Have you been in contact with any confirmed COVID-19 positive patients? (Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.) *
DO YOU CURRENTLY HAVE ANY OF THESE SYMPTOMS? (Please check all that apply) *
Required
If the answer to any of these questions change prior to the scheduled appointment or any of these symptoms mentioned deem it necessary to do so, I agree to notify Upland Dental at (909) 206-4321 as soon as possible in order to keep the staff and other patients safe by rescheduling the appointment or requesting a virtual appointment. *
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