Aquadental

Name*

First Last

Date Of Birth*

MM

DD

YYYY

Has there been any changes to your address or contact information?*

YES
NO

New Address*

Street Address Address Line 2 City Province Postal Code

Has there been any changes to your insurance information? PLEASE READ CAREFULLY*

**Please be aware of your maximum , how much is left on your insurance, and when your insurance year ends. This needs to be discussed before your appointment .We can no longer use chair time or PPE to discuss these matters.

YES
NO

New Insurance Details*

Are you aware we did not add a COVID fee, nor did we increase our prices? Our goal to is to help everyone affected by this unfortunate situation.*

YES
NO

Are you aware we had to make the difficult decision to stop taking assignment? It is FEE for SERVICE on day of treatment now. This will help us avoid transferring the increase in cost on to you.*

YES
NO

Medical History*

Please update any new and old medical conditions. (i.e Hypertension, diabetes, pregnancy, anxiety etc). Type NA if not applicable.

Medication & Supplements*

Please update any new and old medications and supplements you are taking. (i.e Prescription, Over the counter, vitamins) Type NA if not applicable.

COVID-19 SCREENING

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?*

YES
NO

Are you/they having shortness of breath or other difficulties breathing?*

YES
NO

Do you/they have a cough?*

YES
NO

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*

YES
NO

You selected YES, Please provide more details*

Have you/they experienced recent loss of taste or smell?*

YES
NO

Are you/they in contact with any confirmed COVID-19 positive patients?*

YES
NO

Is your/their age over 60?*

YES
NO

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

YES
NO

You selected YES, Please provide more details*

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

YES
NO

You specified YES to one of the above questions, please provide more details.*

Have you been tested positive to COVID-19?*

YES
NO

When did you get tested positive to COVID-19?*

MM

DD

YYYY

Have you been tested again as negative to COVID-19?*

YES
NO

When did you get tested negative to COVID-19?*

MM

DD

YYYY

I am aware I cannot enter the office without a mask.*

YES
NO

Are you aware you have to contact our office if you develop COVID symptoms within 14 days of your appointment so we may notify the people who were working on the day of your appointment?*

YES
NO

Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment. Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

NA*

NA

I agree to above mentioned consent.

Signature of Patient or Legal Guardian*

Today's Date: 07/27/2024

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Aqua Dental

COVID-19 SCREENING