Patient Name*
Email*
Phone*
Date of Birth*
Patient's health history?* YesNo
Patient's dental insurance?* YesNo
Patient's contact information?* YesNo
At our office, your safety is our top priority. We want to assure you that while many things have changed, one thing remains the same, our unwavering commitment to patient safety to ensure you are both, safe and comfortable.
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.
Therefore, we ask that you answer a number of “screening” questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.
Have you or members of your household been diagnosed as having COVID-19?* YesNo
[group covid-19-yes]
If yes, who and when?
[/group]
1) Do you have one or more of the following symptoms: (Check all that apply)* FeverShortness of breathRunny NoseSore ThroatDry CoughNone of the above
2) Within the last 14 days, have you come in contact with a person who has a confirmed COVID-19 diagnosis?* YesNo
3) I understand that there is a risk that a person attending Naperville Dental Specialists may be infected with COVID-19 and expose me to the virus.* Agree
4) In light of the known risks in relation to contracting COVID-19, I knowingly and willingly consent to receive dental and/or orthodontic treatment during the COVID-19 pandemic.* YesNo
Signature
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