Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
Are you/they having shortness of breath or other difficulties breathing?
Do you/they have a cough?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Have you/they experienced recent loss of taste or smell?
Are you/they in contact with any confirmed COVID-19 positive patients?
Is your/their age over 60?
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your
Informed Consent During COVID-19
C COVID-19 is an infectious virus that currently has no direct treatment. While we have taken reasonable steps to limit the potential for transmission of COVID-19 in our
office, you agree that you understand transmission of COVID-19 is still possible.
By necessity, dentistry requires that our staff and health care providers be within 6 feet of you and will
need to touch you and, potentially, your personal objects. You understand that person-to-person contact may
increase the chance of COVID-19 transmission. It may be necessary that you quarantine and/or take other
steps in the event it is determined that you may have been exposed to COVID-19.
You further understand that recommendations and guidelines regarding COVID-19 are subject to modification.
I have been given the opportunity to ask questions and all my questions have been answered.