Lonsdale Family Dental Clinic Covid-19 Screening Questionnaire Name* First Last Date Of Birth* MM DD YYYY Have you been completely vaccinated for COVID-19?*YESNOPREFER NOT TO ANSWERDo you/they have fever or have you/they felt hot or feverish recently (14-21 days)?*YESNOAre you/they having shortness of breath or other difficulties breathing?*YESNODo you/they have a cough?*YESNOAny other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*YESNOYou selected YES, Please provide more details*Have you/they experienced recent loss of taste or smell?*YESNOAre you/they in contact with any confirmed COVID-19 positive patients?*YESNOIs your/their age over 60?*YESNODo you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*YESNOHave you/they traveled in the past 14 days outside your state? (as relevant to your location)*YESNOWhere have you traveled to?*Have you been tested positive to COVID-19?*YESNOWhen did you get tested positive to COVID-19?* MM DD YYYY Have you been tested again as negative to COVID-19?*YESNOWhen did you get tested negative to COVID-19?* MM DD YYYY Patients who are well but who have a sick family member at home with COVID-19 should consider postponing/rescheduling treatment. Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with dental treatment.Covid-19 Risk Acknowledgement Form*COVID‐19 PANDEMIC DENTAL TREATMENT NOTICE AND ACKNOWLEDGEMENT OF RISK FORM Our goal is to provide a safe environment for our patients and staff, and to advance the safety of our local community. This document provides information we ask you to acknowledge and understand regarding the COVID‐19 virus. The COVID‐19 virus is a serious and highly contagious disease. The World Health Organization has classified it as a pandemic. You could contract COVID‐19 from a variety of sources. Our practice wants to ensure you are aware of the additional risks of contracting COVID‐19 associated with dental care. The COVID‐19 virus has a long incubation period. You or your healthcare providers may have the virus and not show symptoms and yet still be highly contagious. Determining who is infected by COVID‐19 is challenging and complicated due to limited availability for virus testing. Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office. Dental procedures create water spray which is one way the disease is spread. The ultra‐fine nature of the water spray can linger in the air for a long time, allowing for transmission of the COVID‐19 virus to those nearby. You cannot wear a protective mask over your mouth to prevent infection during treatment as your health care providers need access to your mouth to render care. This leaves you vulnerable to COVID‐19 transmission while receiving dental treatment. I confirm that I have read the Notice above and understand and accept that there is an increased risk of contracting the COVID‐19 virus in the dental office or with dental treatment. I further confirm that I understand and accept the additional risk of contracting COVID‐19 from contact at this office. I also acknowledge that I could contract the COVID‐19 virus from outside this office and unrelated to my visit here. *Due to Covid-19, there will be a $15.00 surcharge for required personal protective equipment used per visit as recommended by the CDC* I agree to above mentioned consent.Signature of Patient or Legal Guardian*Today's Date: 05/05/2024UsernameThis is a hidden field Consent TextCOVID‐19 PANDEMIC DENTAL TREATMENT NOTICE AND ACKNOWLEDGEMENT OF RISK FORM Our goal is to provide a safe environment for our patients and staff, and to advance the safety of our local community. This document provides information we ask you to acknowledge and understand regarding the COVID‐19 virus. The COVID‐19 virus is a serious and highly contagious disease. The World Health Organization has classified it as a pandemic. You could contract COVID‐19 from a variety of sources. Our practice wants to ensure you are aware of the additional risks of contracting COVID‐19 associated with dental care. The COVID‐19 virus has a long incubation period. You or your healthcare providers may have the virus and not show symptoms and yet still be highly contagious. Determining who is infected by COVID‐19 is challenging and complicated due to limited availability for virus testing. Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office. Dental procedures create water spray which is one way the disease is spread. The ultra‐fine nature of the water spray can linger in the air for a long time, allowing for transmission of the COVID‐19 virus to those nearby. You cannot wear a protective mask over your mouth to prevent infection during treatment as your health care providers need access to your mouth to render care. This leaves you vulnerable to COVID‐19 transmission while receiving dental treatment. I confirm that I have read the Notice above and understand and accept that there is an increased risk of contracting the COVID‐19 virus in the dental office or with dental treatment. I further confirm that I understand and accept the additional risk of contracting COVID‐19 from contact at this office. I also acknowledge that I could contract the COVID‐19 virus from outside this office and unrelated to my visit here. *Due to Covid-19, there will be a $15.00 surcharge for required personal protective equipment used per visit as recommended by the CDC*HideAgeThis is a hidden field ← djajal12 → abonfigli