Covid-19 consent and questionnaire
Even after following protocols set by the American Dental Association and our state’s dental association, it is still possible to contract COVID-19 while at a dental office. We are following all guidelines to minimize the risk of transmission.    
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Email *
1. Appointment Date *
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2. Patient First Name *
3. Patient Last Name *
4. Guardian First Name
5. Guardian Last Name
6. Relationship to the Patient *
7. Cell phone # *
8. I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic. I understand that the COVID-19 virus has a long incubation period during which carriers of this virus may not show symptoms and may still be highly contagious. *
9. I understand that – due to the frequency of visits of other dental patients, the characteristics of the COVID-19 virus, and the characteristics of dental procedures – I have an elevated risk of contracting the COVID-19 virus simply by being in a dental office. *
10. I confirm that I am not presenting any of these COVID-19 symptoms: Fever(100.4° F degrees), Shortness of breath, Dry cough, Runny nose, Sore throat *
11. If you have above symptoms, do you have symptoms in past 14 days?
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12. Have you had the COVID virus within past 14 days? *
13. Have you been around any individual who has had these symptoms or tested positive for COVID-19 within past 14 days? *
14. If yes, do you get tested for antibody or Corona virus?
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15. I confirm that I have not been in contact with a person who has been diagnosed with COVID-19 within the past 14 days. *
16. If you have been in contact with a person who has been diagnosed with Covid-19 for past 14 days, do you get tested for antibody or Corona virus?
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17. I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. And the CDC recommends social distancing of at least six feet for a period of 14 days to anyone who has recently traveled, and this is not possible with dentistry. *
18. Have you or others accompanying you to today’s appointment traveled outside of our local area or outside of the US within the past 14 days? *
19. If yes, please confirm you have no symptoms or get tested for antibody or was tested positive and free of Corona virus for past 14 days.
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21. Have you been vaccinated for Covid-19?
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How many doses?
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20. Note to the office
Patient/Guardian Signature *
A copy of your responses will be emailed to the address you provided.
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