Patient Advisory & Acknowledgement Step 1 of 2 50% Supplemental Informed ConsentThank you for your continued trust in our practice. As with the transmission of any communicable disease such as the flu or common cold, you may be exposed to Covid-19, also known as the "Coronavirus", at any time or in any place. Be assured that our office has always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and we will continue to do so. Despite 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 at your gym, grocery store, or favorite restaurant. "Social Distancing" nationwide has reduced the transmission of the Coronavirus. Although we have taken measures to provide social distancing in our office, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, doctor, staff and sometimes other patients at all times.Although exposure is unlikely, do you accept the risk and consent to treatment?*YesNoPatient's Name*Patient / Guardian's Signature*Date* Date Format: MM slash DD slash YYYY Receiving Dental Treatment During the COVID-19 PandemicDear Patient: You are coming to our office 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.Please Answer "Yes" Or "No" To The Following Questions:Have you been diagnosed positive for the COVID-19 virus at any time?*YesNoAre 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 travelled to any foreign country?*YesNoWithin the last 14 days, have you travelled within the US or to any foreign country?*YesNoIf so, where did you travel?Patient / Guardian Signature*Date* Date Format: MM slash DD slash YYYY
