BALA INSTITUTE OF ORAL SURGERY

15 N. PRESIDENTIAL BLVD, SUITE 301 s  BALA CYNWYD, PA 19004
(610) 667-6161 s WWW.BALASURGERY.COM

In the continually evolving COVID-19 crisis, we are complying with all protocols to ensure the health and safety of our patients and clinical staff, following U.S. Centers for Disease Control and Prevention (CDC) and the PA Department of Health recommendations. At this time, if an oral surgery appointment is deemed urgent, we are scheduling patients in the office during limited hours. All patients are required to follow specific guidelines, fill out the following form and submit it online prior to their scheduled appointment. Thank you for your cooperation and understanding.

WITHIN THE PAST 14 DAYS:

PATIENT GUIDELINES

• If you are having sedation, after checking in, your driver must stay in their car and reachable via their cell phone for our staff.
• If you do not need a driver, you are not having sedation or you are not a minor, please do not bring additional people with you.
• Only patients will be allowed to enter the office (unless the patient is a minor – then one parent/guardian will be permitted in). Our waiting room is closed.No children will be allowed in the office. Please make necessary arrangements for child care.
• All patients will have their temperature taken upon entering our office via touch-free infrared thermometers.
• If you enter our office with any type of cough, you will be asked to leave and call us to reschedule your appointment.

By signing below, I understand the above guidelines and have answered the questions honestly and to the best of my knowledge.

BALA INSTITUTE OF ORAL SURGERY
15 N. Presidential Blvd., Suite 301 • Bala Cynwyd, PA 19004
(610) 667-6161 • www.balasurgery.com

COVID‐19 PANDEMIC EMERGENCY DENTAL TREATMENT NOTICE AND ACKNOWLEDGEMENT OF RISK FORM

As with the transmission of any communicable disease, you have the potential to be exposed to COVID-19, also known as the Coronavirus, at any time or any place. Be assured that we have always followed state and federal regulations and utilized universal precautions, personal protective equipment, and disinfection protocols to limit transmission of all diseases in our office. We are taking measures above and beyond to ensure your safety as well as the safety of our staff. In addition to our recommended sterilization processes, we have implemented advanced air purification devices in each operatory and will be wearing more protective masks, gowns, head and shoe coverings.

Despite our careful attention to sterilization, disinfection and use of social distancing, there is still a chance that you could be exposed to an illness in our office, just as you might be at your local grocery store or favorite restaurant. Although we have taken measures to provide social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, oral surgeon and dental staff.

The COVID‐19 virus has a long incubation period. You or your healthcare providers may have the virus and not show symptoms and yet still be highly contagious. Determining who is infected by COVID‐19 is challenging and complicated due to limited availability for virus testing. Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office.

Dental procedures create water spray which is one way the disease is spread. The ultra‐fine nature of the water spray can linger in the air for a long time, allowing for transmission of the COVID‐19 virus to those nearby. You cannot wear a protective mask over your mouth to prevent infection during treatment as your health care providers need access to your mouth to render care. This leaves you vulnerable to COVID‐19 transmission while receiving dental treatment.

By signing below, I confirm that I have read the notice above and understand and accept that there is an increased risk of contracting the COVID‐19 virus in the dental office or with dental treatment. I also acknowledge that I could contract the COVID‐19 virus from outside this office and unrelated to my visit here.