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Patient Advisory and Acknowledgment
Receiving Dental Treatment During the COVID-19 Pandemic
Dear Patient/Parent/guardian/caregiver:

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.


Are you or your child currently awaiting the results of a COVID-19 test?
Do you or your child have a fever? *
Do you or your child have a runny nose?
Within the last 14 days, have you traveled to internationally? *
Do you or your child have a fever? *
Do you or your child have shortness of breath? *
Do you or your child have a sore throat? *
Within the last 14 days have you travelled within the United States? *

Thanks for submitting!

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