Receiving Dental Treatment During the COVID-19 Pandemic

Dear Patient:

You have presented to the office today because you have an urgent dental condition that must be treated at the time and cannot be postponed until the current COVID-19 risk period abates.

Please be advised of the following:

While our office complies with the State Health Department and the Center for Disease Control and Prevention guidelines. To prevent the spread of the COVID-19 virus, we cannot make any guarantees.

Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge.

To reduce the risk of spreading COVID-19, we have asked you several “screening” questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers. 

Patient/Responsible Party: ___________________________________________________ Date:______________________________

Please answer “YES” or “NO” with your initials, to the following questions:

Do you have a fever? ____YES  ____NO

Do you have shortness of breath? ___YES___NO

Do you have a dry cough? ___YES ___NO

Do you have a runny nose? ___YES___NO

Do you have a sore throat? ___YES___NO

Within the last 14 days, have you traveled to any foreign country? _ YES ___NO

Within the last 14 days, have you traveled within the United States? __YES __NO

If so, where? _________________________________________________