All Fields RequiredPatient NamePatient NameField is required!Field is required!Appointment TimeSelect a timeField is required!Field is required!Patient Date of Birthmm/dd/yyyyField is required!Field is required!If parent/guardian is accompanying patient, please provide the following information:Parent/Guardian NameParent/Guardian Full NameField is required!Field is required!Parent/Guardian Date of Birthmm/dd/yyyyField is required!Field is required!1. Are you and/or anyone accompanying you today displaying any of the following symptoms?Fever of 100.4 or higher?NoYesField is required!Field RequiredCough?NoYesField is required!Field RequiredShortness of breath or difficulty breathing?NoYesField is required!Field RequiredRepeated shaking and/or chills?NoYesField is required!Field RequiredMuscle pain? NoYesField is required!Field RequiredHeadache? NoYesField is required!Field RequiredSore throat?NoYesField is required!Field RequiredNew loss of taste or smell?NoYesField is required!Field RequiredHave you been in close contact with a person known to have COVID-19/Coronavirus within the last 10 days?NoYesField is required!Field RequiredHave traveled outside of the continental U.S. in the last 14 days?NoYesField is required!Field RequiredIF YOU SELECTED YES TO ANY OF THE ABOVE QUESTIONS, PLEASE CALL OR TEXT 606-224-3688**********Please check that you have read and understand the statements below.Anyone over the age of 3 is required to wear a mask when entering our office. If you do not have your own mask with you today, we will provide you with one. This will be protocol for the foreseeable future, so we encourage you to wear your own mask in the future.Patient temperature will be taken as well as anyone accompanying the patient prior to entry into the office.Field is required!Field is required!CONSENTCONSENTOur goal is to provide a safe environment for our patients and staff, and to advance the safety of our community. We ask you to acknowledge and understand the following information regarding the COVID-19 virus. Determining who is infected by COVID-19 is challenging and complicated due to limited availability for virus testing. We are taking every precaution we can via proper sanitation techniques and personal protective equipment to prevent transmission in either direction.The patient,Patient's Full NameField is required!Field is required! ACKNOWLEDGEMENT ACKNOWLEDGEMENTYou are receiving dental care during the events of a COVID-19 National Emergency. Please be advised, judgement 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 understand that this action is just a business decision and agree this represents a compromise between the patient and the doctor. Accordingly, this agreement is not an admission of any liability regarding the doctor, practice, associates, employees, successors, assigns, legal representatives, organizers, sponsors, and supervisors, against any claims, and actions. I have carefully read this release and understand its contents, and I am signing it of my own free act.Patient or Parent/Guardian-Type Legally Binding Signature HerePatient or Parent/Guardian Full NameField is required!Field is required!DateSelect a dateField is required!Field is required!All Fields RequiredSubmit Form