COVID-19 Form Patient Advisory and AcknowledgmentReceiving Dental Treatment During the COVID-19 PandemicDear Patient:You have come to our office today for a routine dental evaluation and/or treatment that will be done during the COVID-19 pandemic. Please be advised of the following:While our office complies with State Health Department and the Centers for Disease Control and Prevention infection control 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.In order to reduce the risk of spreading COVID-19, we have asked you a number of “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* Date Format: MM slash DD slash YYYY ARE YOU CURRENTLY AWAITING THE RESULTS OF A COVID-19 TEST?*YesNoDO YOU HAVE A FEVER?*YesNoDO YOU HAVE ANY SHORTNESS OF BREATH?*YesNoDO YOU HAVE A DRY COUGH?*YesNoDO YOU HAVE A RUNNY NOSE?*YesNoDO YOU HAVE A SORE THROAT?*YesNoDO YOU HAVE SNEEZING, WATERY EYES, AND/OR SINUS PAIN/PRESSURE THAT IS UNUSUAL AND NOT RELATED TO SEASONAL ALLERGIES?*YesNoHAVE YOU EXPERIENCED HEADACHES, FATIGUE, OR WEAKNESS?*YesNoHAVE YOU LOST YOUR SENSE OF TASTE AND/OR SMELL?*YesNoWITHIN THE LAST 14 DAYS, HAVE YOU TRAVELED WITHIN THE UNITED STATES? IF SO, WHERE?*CAPTCHA If you have an issue submitting this form, please download our paperwork here and call our staff to discuss how you can submit it.