leesburg

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.

COVID-19 DENTAL TREATMENT INFORMED CONSENT*

You are receiving dental care during the pandemic events of COVID-19 National Emergency. Please be advised that there may be increased risk of exposure from doctors, staff, other patients, and the treatment facility. We are taking precautions to limit the spread of this disease, but there is still a possibility of transmission.

I understand that 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 on 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 knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic. I do hereby acknowledge the health risks of the COVID-19 virus during this National Emergency and I willfully request and authorize the doctors and staff at Downtown Family Dental of Leesburg to perform any necessary dental and/or orthodontic services. I will be responsible for any charges incurred for my treatment.

I agree to above mentioned consent.

Signature of Patient or Legal Guardian*

Today's Date: 09/28/2023

Username

This is a hidden field

Consent Text

You are receiving dental care during the pandemic events of COVID-19 National Emergency. Please be advised that there may be increased risk of exposure from doctors, staff, other patients, and the treatment facility. We are taking precautions to limit the spread of this disease, but there is still a possibility of transmission.

I understand that 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 on 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 knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic. I do hereby acknowledge the health risks of the COVID-19 virus during this National Emergency and I willfully request and authorize the doctors and staff at Downtown Family Dental of Leesburg to perform any necessary dental and/or orthodontic services. I will be responsible for any charges incurred for my treatment.

HideAge

This is a hidden field

Downtown Family Dental Of Leesburg