Smallwood and McKown-Smallwood Family, Cosmetic, & Sleep Dentistry Covid-19 Screening Questionnaire Name* First Last Date Of Birth* Month Day Year 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?* Month Day Year Have you been tested again as negative to COVID-19?* YES NO When did you get tested negative to COVID-19?* Month Day Year 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 Treatment Consent 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. Please read this in its entirety, as it also provides instructions on updated protocols to expect during your upcoming appointment. Upon arrival to your reserved appointment we ask that you call the office, at 540-433-2288, to alert the team that you are here and ready, and continue to remain in your vehicle. The clinical team will be alerted and when your chair is available, you will be contacted and given further instructions for entry. You will meet your clinical team member at the side door, be taken back to your appointed room, asked to either wash your hands or use hand sanitizer, and have your temperature taken with a no-contact forehead thermometer. Your appointment will proceed and when you are finished, you will check out at the front of the office and exit through the main entrance. The reception area and restrooms are closed at this time, so we ask that you use the restroom and brush/floss before your appointment. Our practice complies with the Virginia State Health Department and the CDC infection control guidelines to prevent the spread of the COVID-19 virus; however, we cannot make any guarantees. Our team is screened daily upon arrival and all patients are screened prior to their appointment with a screening questionnaire and upon arrival with a temperature check to make sure all are feeling healthy and well. We are a place of public accommodation and want to ensure the safety of our team and our patients. We ask you to reschedule an upcoming appointment if there is any uncertainty on your current health situation. 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 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. I will hold harmless and indemnify, the doctor, practice, associates, employees, successors, assigns, legal representatives, organizers, sponsors, and supervisors, against any claims, and actions, in exchange for dental treatment during the events of this COVID-19 National Emergency. I make this decision of my own free will relying upon my knowledge and judgment of any injury I may have sustained or possible transmission of COVID-19 during treatment and my decision to release has not been affected by any false statements or representations pertaining to those injuries. I have carefully read this release and understand its contents, and I am signing it of my own free act. I agree to above mentioned consent.Signature of Patient or Legal Guardian*Today's Date: 11/23/2025HiddenUsernameThis is a hidden field HiddenConsent TextOur 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. Please read this in its entirety, as it also provides instructions on updated protocols to expect during your upcoming appointment. Upon arrival to your reserved appointment we ask that you call the office, at 540-433-2288, to alert the team that you are here and ready, and continue to remain in your vehicle. The clinical team will be alerted and when your chair is available, you will be contacted and given further instructions for entry. You will meet your clinical team member at the side door, be taken back to your appointed room, asked to either wash your hands or use hand sanitizer, and have your temperature taken with a no-contact forehead thermometer. Your appointment will proceed and when you are finished, you will check out at the front of the office and exit through the main entrance. The reception area and restrooms are closed at this time, so we ask that you use the restroom and brush/floss before your appointment. Our practice complies with the Virginia State Health Department and the CDC infection control guidelines to prevent the spread of the COVID-19 virus; however, we cannot make any guarantees. Our team is screened daily upon arrival and all patients are screened prior to their appointment with a screening questionnaire and upon arrival with a temperature check to make sure all are feeling healthy and well. We are a place of public accommodation and want to ensure the safety of our team and our patients. We ask you to reschedule an upcoming appointment if there is any uncertainty on your current health situation. 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 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. I will hold harmless and indemnify, the doctor, practice, associates, employees, successors, assigns, legal representatives, organizers, sponsors, and supervisors, against any claims, and actions, in exchange for dental treatment during the events of this COVID-19 National Emergency. I make this decision of my own free will relying upon my knowledge and judgment of any injury I may have sustained or possible transmission of COVID-19 during treatment and my decision to release has not been affected by any false statements or representations pertaining to those injuries. I have carefully read this release and understand its contents, and I am signing it of my own free act.HiddenHideAgeThis is a hidden field ← Tucker → Hmreeves
