I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic. I understand that the COVID-19 virus has a long incubation period during which carriers of this virus may not show symptoms and may still be highly contagious. *
I understand that – due to the frequency of visits of other dental patients, the characteristics of the COVID-19 virus, and the characteristics of dental procedures – I have an elevated risk of contracting the COVID-19 virus simply by being in a dental office. *
10. I confirm that I am not presenting any of these COVID-19 symptoms: Fever(100.4° F degrees), Shortness of breath, Dry cough, Runny nose, Sore throat *
11. If you have above symptoms, do you have symptoms in past 14 days?
12. Have you had the COVID virus within past 14 days? *
13. Have you been around any individual who has had these symptoms or tested positive for COVID-19 within past 14 days? *
14. If yes, do you get tested for antibody or Corona virus?
15. I confirm that I have not been in contact with a person who has been diagnosed with COVID-19 within the past 14 days. *
16. If you have been in contact with a person who has been diagnosed with Covid-19 for past 14 days, do you get tested for antibody or Corona virus?
17. 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 six feet for a period of 14 days to anyone who has recently traveled, and this is not possible with dentistry. *
18. Have you or others accompanying you to today’s appointment traveled outside of our local area or outside of the US within the past 14 days? *
19. If yes, please confirm you have no symptoms or get tested for antibody or was tested positive and free of Corona virus for past 14 days.