Patient Screening and Consent

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Patient Name
Patient Name
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Appointment Time
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Patient Date of Birth
mm/dd/yyyy
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If parent/guardian is accompanying patient, please provide the following information:
Parent/Guardian Name
Parent/Guardian Full Name
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Parent/Guardian Date of Birth
mm/dd/yyyy
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1. Are you and/or anyone accompanying you today displaying any of the following symptoms?

Fever of 100.4 or higher?
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Cough?
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Shortness of breath or difficulty breathing?
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Repeated shaking and/or chills?
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Muscle pain?
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Headache?
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Sore throat?
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New loss of taste or smell?
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Have you been in close contact with a person known to have COVID-19/Coronavirus within the last 10 days?
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Have traveled outside of the continental U.S. in the last 14 days?
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IF YOU SELECTED YES TO ANY OF THE ABOVE QUESTIONS, PLEASE CALL OR TEXT 606-224-3688

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Please check that you have read and understand the statements below.
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CONSENT

Our 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 Name
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ACKNOWLEDGEMENT

You 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 Here
Patient or Parent/Guardian Full Name
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Date
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