COVID-19 CONSENT AND QUESTIONNAIRE -

Patient's Name (You may list multiple children if the answer to all of the below questions are "no")*

First Last

Parent's email address (will not be given, sold etc)*

Have you, your child, or others accompanying you to today's appointment within the past fourteen (14) days: (a)-Travelled out of New York (b)-been in close contact with a suspected or confirmed COVID-19 case, or (c)-had any symptoms consistent with COVID-19, or (d)-had a positive COVID-19 test?*

Yes
no

STOP. Please call our office at 516-932-1101 to discuss your answer to the above question. In certain circumstances, we may need to defer your appointment based upon NYS mandate. You will not be able to complete and submit this form.*

Do you, your child, or others accompanying you to today's appointment or other recent acquaintances have a fever (defined as above 99.6 degrees F?:*

Yes
No

Do you, your child, or others accompanying you to today's appointment or other recent acquaintances have a cough?*

Yes
No

Do you, your child, or others accompanying you to today's appointment or other recent acquaintances have shortness of breath or trouble breathing?*

Yes
No

Do you, your child, or others accompanying you to today's appointment or other recent acquaintances have persistent pain, pressour or tightness in the chest?*

Yes
No

Electronic Signature*

I understand that if the answer to any of these questions is “yes”, I will be asked to reschedule today’s dental appointment.

By checking this box, I hereby certify that I am providing truthful and accurate answers to the questions above.

Name of person who filled out this form and checked the above box:*

…………….INFORMED CONSENT IN THE ERA OF COVID-19 ………………….. Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19 at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseased in our office and continue to o so. Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might anywhere outside of your home. "Social distancing" nationwide has reduced the transmission of the Coronavirus. Although we have taken measures to provide social distancing in our office, due to the nature of the procedures that we provide, it is not possible to maintain social distancing between the patient, dentist, dental staff and office staff and other patients at all times. Although exposure is highly unlikely, by consenting to treatment in our office, you are assuming that inherent risk*

Agree
Disagree

Signature*

Please sign or otherwise initial.

Today's Date*

What is 2+3=*

So you don’t have to do a “Captcha” challenge…. Answering correctly will enable the “submit” button

Email

This field is for validation purposes and should be left unchanged.