SCREENING QUESTIONS

    COVID-19 Pandemic Dental Treatment Consent Form

    I, knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.

    I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing.

    Dental procedures create water spray. It is unclear how long the ultra-fine nature of the spray may linger in the air, which can transmit the COVID-19 virus. (Initial)

    PLEASE CAREFULLY REVIEW & CHECK YES or NO:

    YesNo

    YesNo

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    YesNo

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    I will report to this office in the next 48 hours should I begin to develop any symptoms (as listed above) of COVID-19.

    I understand the CDC recommends social distancing of at least 6 feet; this is not possible with dentistry.

    When I present for my appointment if my temperature reading is over 100 degrees my appointment will be rescheduled

    I have reviewed and completed this form on