COVID-19 DENTAL TREATMENT CONSENT FORM

     

    I confirm that I am not presenting any of the following symptoms of COVID-19 listed below:

     

    Do you have a cough?


    Do you have a fever now or have you in the past 14-21 days?


    Have you come in contact with any confirmed COVID-19 positive patients in the last 14 days?


    Are you experiencing shortness of breath or difficulty breathing?


    Are you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?


    Have you experienced recent loss of taste or smell?


    Are you over the age of 60?


    Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?


    Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)


    I have been informed that the office has implemented preventative measures intended to reduce the spread of Covid-19. I hereby acknowledge that by submitting this wellness form, I am agreeing to all current or future policies as it relates to Covid-19, and I give my permission for your team to proceed with providing care.
    Check here if you accept these terms.

     

     

    CONTACT US HERE…

    or give us a call at 516-671-0817.

    Glen Cove NY Dentist, One School Street