Patient Advisory and AcknowledgmentReceiving Dental Treatment During the COVID-19 PandemicDear Patient:You have come to our offce 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 offce 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.PATIENT/RESPONSIBLE PARTY*DATE* MM slash DD slash YYYY LOCATION* Wilmington Newark ARE YOU CURRENTLY AWAITING THE RESULTS OF A COVID-19 TEST?* Yes No DO YOU HAVE A FEVER?* Yes No DO YOU HAVE ANY SHORTNESS OF BREATH?* Yes No DO YOU HAVE A DRY COUGH?* Yes No DO YOU HAVE A RUNNY NOSE?* Yes No DO YOU HAVE A SORE THROAT?* Yes No DO YOU HAVE SNEEZING, WATERY EYES, AND/OR SINUS PAIN/PRESSURE THAT IS UNUSUAL AND NOT RELATED TO SEASONAL ALLERGIES?* Yes No HAVE YOU EXPERIENCED HEADACHES, FATIGUE, OR WEAKNESS?* Yes No HAVE YOU LOST YOUR SENSE OF TASTE AND/OR SMELL?* Yes No WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELLED TO ANY FOREIGN COUNTRY?* Yes No WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELLED WITHIN THE UNITED STATES?* Yes No IF SO, WHERE?*
