ADA COVID Patient Screening Form Patient Details

ADA COVID Patient Screening Form ADA COVID Patient Screening Form

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

For testing, see the list of State and Territorial Health Department Websites for your specific area's information.

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 Heatlh 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 our 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 our knowledge.

  •  YES
  •  NO
  •  YES
  •  NO

I understand that the information I have given is, to the best of my knowledge, correct and that it will be held in the strictest of confidence. Because my child is a minor, it is necessary that signed permission is obtained for a parent or legal guardian before any dental services can be rendered. I understand that during my childs visit, I must remain at the office until my child is dismissed unless the office has made arrangements with my family. I give my consent to Dr. Dimock, Dr. Weinberg, Dr. Cherry, and their staff to perform such treatment, services, medication, behavior management techniques, local anesthesia or analgesia to treat any dental/oral deficiency, abnormality and/or infection.

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