Patient Name* First Last Date MM slash DD slash YYYY ADA Patient Screening FormDo you/they have fever or have you/they felt hot or feverish recently (14-21 days)?* No Yes Are you/they having shortness of breath or other difficulties breathing?* No Yes Do you/they have a cough?* No Yes Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?* No Yes Have you/they experienced recent loss of taste or smell?* No Yes Are you/they in contact with any confirmed COVID-19 positive patients?* No Yes Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment. For testing, see the list of State and Territorial Health Department Websites for your specific area's information. Our practice complies with State Health Department and the CDC infection control guidelines to prevent the spread of the COVID 19 virus, however, we cannot make any guarantees. Our team is screened daily and, to the best of their knowledge, have not been exposed to the virus. We are a place of public accommodation, and other persons (including other patients) could be infected, with or without their knowledge. I hereby knowingly and willingly consent to have dental treatment completed at this time. I will hold harmless and indemnify, the doctor, practice, associates, employees, successors, assigns, legal representatives, organizers, sponsors, and supervisors, against any claims, and actions, in exchange for dental treatment during the events of COVID 19 National Emergency. I make this decision of my own free will relying upon my knowledge and 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 have carefully read this release and understand its contents, and I am signing it of my own free act.Draw your signature into the box below.*Relationship to the patient*PatientParentGrandparentGuardianSiblingLegal representativeYour name (if not the patient)* First Last CAPTCHA Δ