VivaCovidScreening

Location*

DALLAS
RICHARDSON

Name*

First Last

Date Of Birth*

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

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

YES
NO

Do you/they have a cough?*

YES
NO

You selected YES, please provide more details*

Any other flu-like symptoms in the past 14-21 days: such as headache, sore throat, nausea, fatigue, chills, repeated shaking, muscle aches, vomiting or diarrhea?*

YES
NO

You selected YES, please provide more details*

Have you had close contact to an individual diagnosed with COVID-19 infection in the past 14 days?*

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*

Are you awaiting results of a lab test for COVID-19?*

YES
NO

Have you previously tested positive for COVID-19?*

YES
NO

When have you tested positive for COVID-19?*

Have you previously tested negative for COVID-19?*

YES
NO

When have you tested negative for COVID-19?*

Have you or a family member previously been asked to self-isolate or self-quarantine in the past 14 days?*

YES
NO

You selected YES, please provide more details*

Patients who are well but who have a sick family member at home with COVID-19 should postpone/reschedule their 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.

The COVID‐19 virus is a serious and highly contagious disease. The World Health Organization has classified it as a pandemic. You could contract COVID‐19 from a variety of sources. Our practice wants to ensure you are aware of the additional risks of contracting COVID‐19 associated with dental care.

The COVID‐19 virus has a long incubation period. You or your healthcare providers may have the virus and not show symptoms and yet still be highly contagious. Determining who is infected by COVID‐19 is challenging and complicated due to limited availability for virus testing.

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 a dental office.

Dental procedures create water spray which is one way the disease is spread. The ultra‐fine nature of the water spray can linger in the air for a long time, allowing for transmission of the COVID‐19 virus to those nearby.

You cannot wear a protective mask over your mouth to prevent infection during treatment as your health care providers need access to your mouth to render care. This leaves you vulnerable to COVID‐19 transmission while receiving dental treatment.

Pursuant to statements from the Center for Disease Control (CDC) and the American Dental Association (ADA), non‐essential or elective treatment, based on the assessment of our staff, will be rescheduled. According to the ADA, dental emergencies are “potentially life threatening and require immediate treatment to stop ongoing tissue bleeding [or to] alleviate severe pain or infection.” The ADA also recommends that urgent dental care which “focuses on the management of conditions that require immediate attention to relieve severe pain and/or risk of infection and to alleviate the burden on hospital emergency departments” be provided in as minimally invasive a manner as possible.

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 further confirm I am seeking treatment for a condition that meets the emergent or urgent criteria noted above. 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 agree to the above.

Signature of Patient or Legal Guardian*

Today's Date: 03/05/2026

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