Hawaii Endodontics

Name*

First Last

Date Of Birth*

Have you been completely vaccinated for COVID-19?*

YES
NO
PREFER NOT TO ANSWER

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

Have you/they traveled in the past 14 days outside your state? (as relevant to your location)*

YES
NO

Where have you traveled to?*

Have you been tested positive to COVID-19?*

YES
NO

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

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

YES
NO

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

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 Consent*

• I knowingly and willingly consent to have emergency dental treatment completed during the COVID-19 pandemic. • I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing. Dental procedures create water spray which is how the disease is spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the COVID-19 Virus. • I understand that due to the visits of other patients, the characteristics of the virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the virus simply by being in a dental office. • I have been made aware of the HDA, CDC, and ADA guidelines that under the current pandemic all non-urgent dental care is not recommended. I understand this risk and confirm that I have an urgent or emergent condition which constitutes severe pain and/or active acute infection. I attest that my pain is severe, and not mild or moderate. • I confirm I am seeking treatment for a condition that meets these criteria. • I confirm that I do not feel sick, have a fever, chills, cough, or any flu-like symptoms. I confirm that I am not presenting any of the following symptoms of COVOID-19 listed below: - Fever - Shortness of Breath • Dry Cough - Runny Nose - Sore Throat • I understand that air travel significantly increases my risk of contracting and transmitting the COVlD-19 virus. And the CDC recommends social distancing of at least 6 feet for a period of 14 days to anyone who has, and this is not possible with dentistry. • I verify that I have not traveled outside the United States (Europe, Middle East, east Asia or others) in the past 14 days to countries that have been affected by COVID-19. • I verify that I have not traveled domestically within the United States by commercial airline, bus, or train within the past 14 days.

I agree to above mentioned consent.

Signature of Patient or Legal Guardian*

Today's Date: 11/21/2025

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Consent Text

• I knowingly and willingly consent to have emergency dental treatment completed during the COVID-19 pandemic.

• I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing. Dental procedures create water spray which is how the disease is spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the COVID-19 Virus.

• I understand that due to the visits of other patients, the characteristics of the virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the virus simply by being in a dental office.

• I have been made aware of the HDA, CDC, and ADA guidelines that under the current pandemic all non-urgent dental care is not recommended. I understand this risk and confirm that I have an urgent or emergent condition which constitutes severe pain and/or active acute infection. I attest that my pain is severe, and not mild or moderate.

• I confirm I am seeking treatment for a condition that meets these criteria.

• I confirm that I do not feel sick, have a fever, chills, cough, or any flu-like symptoms. I confirm that I am not presenting any of the following symptoms of COVOID-19 listed below:
- Fever
- Shortness of Breath • Dry Cough
- Runny Nose
- Sore Throat

• I understand that air travel significantly increases my risk of contracting and transmitting the COVlD-19 virus. And the CDC recommends social distancing of at least 6 feet for a period of 14 days to anyone who has, and this is not possible with dentistry.

• I verify that I have not traveled outside the United States (Europe, Middle East, east Asia or others) in the past 14 days to countries that have been affected by COVID-19.

• I verify that I have not traveled domestically within the United States by commercial airline, bus, or train within the past 14 days.

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HAWAII ENDODONTICS