Wellness/Disclosure Form

    Please fill out this screening form within 24 hours of your scheduled dental appointment.

    This patient disclosure form seeks information from you that we must consider before making decisions in the circumstance of the COVID-19 virus.

    I knowingly & willingly consent to have dental treatment completed during the COVID-19 Pandemic. I understand that The World Health Organization has classified Covid-19 as a pandemic. The COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. It is impossible to determine who has it and who does not; given the current limits in virus testing. Dental procedures produce aerosols allowing the virus to be transmitted via the air. Standard precautions reduce risk as much as possible, but you are unable to wear a protective mask during dental treatment and this is how the virus could be spread.

    A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment radiation, chemotherapy and any prior or current disease or medical condition), can put you at greater risk for contracting COVID-19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us.

    It is also important that you disclose to this office any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus. If you have been exposed or could potentially be a carrier, please stay home and call us to reschedule your appointment.

    Do you have a cough?
    YesNo

    Do you have a fever now or have you in the past 14-21 days?
    YesNo

    Have you come in contact with any confirmed COVID-19 positive patients in the last 14 days?
    YesNo

    Are you experiencing shortness of breath or difficulty breathing?
    YesNo

    Are you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?
    YesNo

    Have you experienced recent loss of taste or smell?
    YesNo

    Are you over the age of 60?
    YesNo

    Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
    YesNo

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

    I understand that I will contact the office (and my Primary Care Physician) if I develop any COVID-19 symptoms within the next 14 days.

    Please record your temperature at home within 24 hours of your appointment and record below.

    Date recorded:

    I confirm that I have read the notice above and understand and accept the increased risk of contracting Covid-19 with having dental treatment or being in this dental office. I fully understand that I can contract the Covid-19 virus from outside the dental office in circumstances unrelated to my dental visit. I acknowledge that the answers I have provided above are true and accurate.

    Signature of Patient/Guardian