English questionnaire Covid-19

With community transmission of communicable diseases, you could be exposed anywhere to infectious diseases including but not limited to Covid-19 (also called Coronavirus). Our office is following the State and Federal regulations and recommended universal personal protection and disinfection protocols to limit the transmission of communicable diseases. However, it is possible that these precautions will not always be successful in blocking the transmission of these diseases. Social distancing nationwide has reduced the transmission of Covid-19, however, it is not possible to provide dental treatment with social distancing between the patient, dentist, staff, and sometimes, other patients.

By presenting yourself or your child for dental treatment, you assume and accept the risk that you or your child may inadvertently be exposed to a communicable disease.

If you have been exposed to a communicable disease prior to your dental appointment, you may spread the disease to the dentist, staff, and to other patients/parents in the practice. Therefore, prior to each appointment, we require you to answer the following questions:

Name *

First Name Last Name

Have you, your child, or others accompanying you to Today's appointment been tested POSITIVE FOR OR BEEN DIAGNOSED AS HAVING COVID-19? *

Yes No

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)? *

Yes No

Are you/they having shortness of breath or other difficulties breathing? *

Yes No

Do you/they have a cough? *

Yes No

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? *

Yes No

Have you/they experienced recent loss of taste or smell? *

Yes No

Are you/they in contact with any confirmed COVID-19 positive patients? Patients who are well but who nave a SICK family member at home wan COVID-19 should consider postponing elective treatment. *

Yes No

Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location) *

Yes No

IF ANY OF YOU HAVE ANY OF THESE SYMPTOMS OR HAVE RECENTLY TESTED POSITIVE FOR OR BEEN DIAGNOSED WITH COVID-19, YOU WILL BE ASKED TO RESCHEDULE YOUR DENTAL APPOINTMENT.

BY SIGNING THIS FORM YOU ACKNOWLEDGE AND ACCEPT THE RISK OF EXPOSURE IN OUR DENTAL OFFICE TO A COMMUNICABLE DISEASE, INCLUDED BUT NOT LIMITED TO COVID-19, AND CONSENT TO TREATMENT

Today's date *

Date

Patient/ Parent's name: *

First Name Last Name

Patient/Parent’s Signature: *

Clear

SUPPLEMENTAL INFORMED CONSENT/QUESTIONNAIRE Communicable Diseases and Your Dentist