Kudent

Name*

First Last

Date Of Birth*

MM

DD

YYYY

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?*

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

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.

DENTAL TREATMENT IN THE ERA OF COVID-19*

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. You could contract COVID‐19 from a variety of sources. Our practice wants to ensure you are aware of the risks of contracting COVID‐19 associated with dental care.
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 an enclosed area.
As a patient, you cannot wear a protective mask during your dental procedure. All dental staff will have personal protective equipment to include masks, face shields or goggles, and gloves. Additionally we space out patients’ visits to protect patients.
Thank you for your continued trust in our practice. Be assured that we have always followed state and federal regulations, recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so. We continue to incorporate additional measures for your safety.

I confirm that I have read the Notice above and understand and accept that there is a risk of contracting the COVID‐19 virus in the dental office or with dental treatment. I also acknowledge that I could contract the COVID‐19 virus from outside this office and unrelated to my visit here.
I have read and understand the information stated above:

I agree to above mentioned consent.

Signature of Patient or Legal Guardian*

Today's Date: 04/24/2024

Username

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Consent Text

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. You could contract COVID‐19 from a variety of sources. Our practice wants to ensure you are aware of the risks of contracting COVID‐19 associated with dental care. 
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 an enclosed area. 
As a patient, you cannot wear a protective mask during your dental procedure. All dental staff will have personal protective equipment to include masks, face shields or goggles, and gloves. Additionally we space out patients’ visits to protect patients. 
Thank you for your continued trust in our practice. Be assured that we have always followed state and federal regulations, recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so. We continue to incorporate additional measures for your safety.

I confirm that I have read the Notice above and understand and accept that there is a risk of contracting the COVID‐19 virus in the dental office or with dental treatment. I also acknowledge that I could contract the COVID‐19 virus from outside this office and unrelated to my visit here. 
I have read and understand the information stated above:

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James Ku, D.D.S.