First Name Last Name Phone Number Date / Time Age Sex MaleFemaleAddress Occupation Temperature In the past 14 days, have you or any member of your household, traveled to any areas with known cases of COVID-19? YesNoIf the answer is YES, please state the exact location In the past 14 days, have you or any member or your household has had any contact with any COVID-19 patient? YesNoHave you or any household member have any history of exposure to any COVID-19 biological material (e.g. saliva)? YesNoHave you had any history of fever for the last 14 days? YesNoHave you had any symptoms in the last 14 days such as: cough, nausea, diarrhea, loss of taste, difficulty breathing, body ache, loss of smell, fever? YesNoUrgent dental need in the last 14 days such as uncontrolled dental/oral pain, swelling, bleeding, infection, trauma? YesNoI give my full consent to have dental treatment done to me in this time of pandemic caused by COVID-19 disease. (Enter Initial) As explained by my dentist, the virus can be transmitted by contact through surfaces and that it can stay in the air for 5 to 72 hours. I am aware that it is impossible to identify who is probable, suspect or COVID-19 positive. Because of this, treatment options are limited to urgent and emergent care to protect me, other patients and the dental staff. (Enter Initials) I recognize that the clinic is adhering to the strictest infection control protocols for my protection and such, I agree cover the fees that this entails. (Enter Initials) I fully understand the risk that because of the nature of the virus, traveling to the clinic, the clinical procedures, and even by simply staying in the dental office, I have a higher chance of contracting the virus. Should I contract the virus, I hereby agree that I shall not hold the dental office liable. (Enter Initials) I am also giving my consent that in accordance to the IATF rules, my identity shall be revealed for possible contact tracing for the interest and safety of the community. (Enter Initials) What is the Patient's or Guardian's Full Name If guardian. Please provide relationship to patient EmailSubmit