New Patient Offer

New Patient Offer

Receive initial exam, x-rays and consultation for only $77.

To take advantage of this amazing offer, simply complete the form below.

Offer Expires:  
10/22/2020

CORONAVIRUS PATIENT CONSENT FORM

Our Governor allowed dental offices to re-open for elective treatment with certain safeguards. All patients, dentists and staff (both front and back) will be screened for COVID-19 daily.

The Center of Disease Control identified nine symptoms associated with Coronavirus.

My Temperature at ___ : ___ am/pm is ____ºF.  [The dental office will fill in this line.]  You will be asked to leave if your temperature meets or exceeds 100.4 ºF. The CDC considers such a reading to indicate a fever.

Please complete all questions below. In the past 24 hours:

  • Cough    
    Yes No
  • Muscle pain    
    Yes No
  • Headache    
    Yes No
  • Sore throat    
    Yes No
  • Shortness of breath or difficulty breathing    
    Yes No
  • Chills    
    Yes No
  • Repeated shaking with chills    
    Yes No
  • New loss of taste or smell    
    Yes No

As of this morning, none of our doctors or staff exhibit any Coronavirus symptoms (using the same screening as above); however, we have NOT BEEN MEDICALLY TESTED for COVID-19 and cannot guarantee that either we or our other patients are Coronavirus-free.

For your safety, our office has increased hygiene measures since the outbreak.

Given this knowledge, and knowing that I possibly could contract COVID-19 at this office (through the doctors, staff, or from other patients, and despite the office’s best intentions), I nevertheless voluntarily wish to continue with my elective dental treatment and hold the doctor and staff harmless should I come down with Coronavirus.

I have read this page and the content in full and have no questions.

Date

  • Name    
  • Phone    
  • Email Address    
  • Patient Signature    
  • _______________________________________
    Temperature taken by (signature)

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