Covid19 Screening Form and Liability Waiver Patient Details

Covid19 Screening Form and Liability Waiver Contact Information

Covid19 Screening Form and Liability Waiver Covid19 Screening Form

Please submit form 24–48 hours prior to your appointment

1. Do you currently have (or have you experienced) any of the following symptoms in the past 21 days

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

(If NO to question 4, skip to question 8)

  •  I think I had it.
  •  I had a positive nasal swab test
  •  I had a positive blood test
  •  I had a positive saliva test
  •  I currently have symptoms and am waiting for a test
  •  24 hours
  •  today
  •  10 days after testing
  •  I was diagnosed negative by a nasal swab test.
  •  I show antibodies to COVID-19 with a blood test.
  •  My doctor said I no longer have it because I don’t have any symptoms.
  •  I don’t have any symptoms, so I don’t have it.

Some medical conditions have been associated with more severe COVID-19 disease. The following questions are an attempt to determine your risk:

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

Covid19 Screening Form and Liability Waiver Covid 19 Liability Waiver

COVID-19 Liability Waiver and Assumption of Risk

The novel coronavirus (“COVID-19”) has been declared a worldwide pandemic by the World Health Organization. It is extremely contagious. The precise methods of spread and contraction are unknown. Further, no known treatment, cure, or vaccine currently exists. COVID-19 CAN CAUSE SERIOUS AND POTENTIALLY LIFE-THREATENING ILLNESS AND EVEN DEATH. The Center for Disease Control and Prevention (the “CDC”) and many other health authorities recommend face masks, social distancing, and other precautions.

Neil L Starr DDS, PC  (hereafter the "Practice") has implemented several measures to attempt to limit the spread of COVID-19 on the Practice’s premises, including, but not limited to, requiring patients to complete the current questionnaire before they are permitted to access the premises. Nevertheless, the Practice cannot prevent you or your child(ren) from becoming exposed to, contracting, or spreading COVID-19 while utilizing the Practice’s services or its premises. If you choose to use the Practice’s services and or enter into its premises, you may be exposing yourself and/or your child(ren) to COVID-19.

ASSUMPTION OF RISK: On behalf of myself and my children, I have read and understand

the above warning concerning the COVID-19. I acknowledge the contagious nature of COVID- 19 and the risks associated with contracting such virus. I hereby knowingly and voluntarily choose to accept the risk of contracting COVID-19 for myself and /or my children in order to use the Practice’s services and to access the Practice’s premises. These services are of such value to me and/or my children that I accept the risk of being exposed to, contracting, and/or spreading COVID-19 to use the Practice’s services and premises in person.

WAIVER OF LIABILITY: I hereby forever hold harmless, release and waive the right, on behalf of myself and my children, to bring suit against the Practice, its owners, officers, directors, managers, agents, employees, or other representatives in connection with exposure, infection, and/or spread of COVID-19 related to using the Practices’ services and premises. I understand that this waiver means that I am giving up the right to bring any claim, including claims for personal injury, death, disease, loss of property, or any other damages, including, but not limited to, claims for negligence, whether known or unknown, foreseen or unforeseen.

CHOICE OF LAW: I understand and agree that the law of the District of Columbia will apply to this contract.

WARRANTY AND REPRESENTATION: I warrant and represent that the answers to the questions herein are true and accurate to the best of my information and belief. I also agree to comply with all procedures implemented by the Practice while attending my appointment.

I HAVE CAREFULLY READ AND FULLY UNDERSTAND ALL PROVISIONS OF THIS RELEASE, AND FREELY AND KNOWINGLY ASSUME THE RISK AND WAIVE MY RIGHTS CONCERNING LIABILITY AS DESCRIBED ABOVE:

I am the parent or legal guardian of the minor named above. I have the right to consent to and, by signing below, I hereby consent to the terms and conditions of this Release

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