Screening Form -

I knowingly, and willingly consent to have 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 been exposed, who has been infected, and who has not been exposed or infected given the current limits in virus testing.

Dental procedures can create significant aerosol of water spray. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the COVID-19 virus.

Please check off each box to represent your Initial. *

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

I certify that I am not presenting any of the following list of symptoms of COVID-19 and have not taken any medications that could mask the symptoms of:

• Fever
• Headache
• Body aches or muscle pain
• Chills
• Shortness of breath or difficulty breathing
• Cough
• Runny Nose
• Sore Throat
• Loss of Smell
• Loss of Taste
• Conjunctivitis

Please check the box to represent your Initial. *

I confirm I have not experienced any of the aforementioned symptoms within the past 72 hours and have not been in close contact with any household members or individuals known to have had any symptoms of upper respiratory disease within the past 14 days.

If I gain knowledge of being exposed within 14 days prior to today’s date, I agree to notify my provider at Framingham Dental Center so that proper isolation measures may be taken, if necessary, to prevent the spread of illness to others.

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