Wellness Screening & Treatment Consent
In compliance with the California Department of Public Health's current guidelines, and for the safety of our patients & staff, we request that you complete this Wellness Screening & Treatment Consent form prior to EACH APPOINTMENT. Please call us (408)269-0337 or e-mail us (info@BlossomValleySmiles.com) if you have any questions. We cannot keep the appointment without this form filled out prior to the appointment. Thank you for your cooperation!
Sign in to Google to save your progress. Learn more
Email *
Full Name *
Patient's name (if different)
In the past 14 days, has the patient, anyone accompanying the patient, or any member of the household had any of the following? *
Yes
No
Fever, felt very hot or feverish
A cough
Shortness of breath or difficulty breathing
Any other flu-like symptoms such as: gastrointestinal upset, unexplained muscle pain, fatigue, or headache
Recent loss of taste or smell
Chills, or repeated shaking with chills
Sore throat
If the patient, family member, or any known contact has been diagnosed with COVID-19, when did that occur?
MM
/
DD
/
YYYY
During the past 14 days, has the patient, a family member, or any known contact had any of the following occur?
Yes
No
Diagnosis of COVID-19
Exposed to someone with symptoms of COVID-19
Tested for COVID-19
Clear selection
If yes, to any of the last questions, please specify the date of occurrence and results:
Does the patient have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders? If yes, then please explain. If no, please enter 'No.' *
Has the patient's medical history changed in the past 12 months? If yes, then please explain. If no, please enter 'No.' *
In the past 14 days, has the patient, anyone accompanying the patient, or any member of the household traveled more than 100 miles away? *
If yes, to the last question: where did they go, by what mode of transportation, & dates of travel? (car, bus, airplane, train, cruise, etc.)?
If the answer to any of these questions changes before the appointment, I agree to notify the office as soon as possible. Also, if the answer is yes to any of the previous questions, I understand this will require a deeper discussion with the dentist before proceeding with the treatment, and there is a possibility I will be asked to reschedule the appointment. Please leave your phone number (next to 'Other') in case the dentist needs to call you. *
Required
Treatment Consent: Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as “Coronavirus,” at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so. Even with our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favorite restaurant. Although we have taken measures to provide social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, dentist, staff and sometimes other patients at all times. Although exposure is unlikely, do you accept the risk and consent to treatment? *
By entering your initials in the line below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge. *
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Blossom Valley Smiles Dental Group & Orthodontics. Report Abuse
Google Forms