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.

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

Signature is required.