Shortness of breathHave you been in contact with anyone confirmed to have Covid-19?YesSoreThroatCoronavirus COVID-19 Screening, Emergency & Elective Treatment ConsentHave you been out in public in the last 2 weeks ( i.e. grocery shopping or other)?Fever over 100.4YesYesHave you had the following symptoms in the last 14 days?NoCoughIf yes, describe:NoAny flu like symptoms?Loss of taste or smell?NoYesNoYesNoHave you traveled outside of US in the last 14 days?If you have any of the above symptoms without fever and not have been exposed, you may proceed with dental treatment. We may postpone your appointment if the provider determines it would be safer.YesNoNoYesSacramento Dental Group has implemented recommended measures by health authorities to ensure the safety of its patients and staff. Further, we have taken steps in creating isolated, air purified rooms and screen our staff daily for added safety. Despite all these precautions, patients should recognize the following: I, the patient, consent to receive emergency or elective treatment from Sacramento Dental Group during the COVID-19 outbreak. I understand there is much to learn about the newly emerged COVID-19 including how it spreads and transmitted. I understand that based on what is currently known about COVID-19 the spread is thought to occur mostly from person-to-person via respiratory droplets among close contacts. I understand that close contact can occur from being within approximately 6 feet of someone with COVID-19 for a prolonged period of time or by having direct contact with infectious secretions from someone with COVID-19. I understand that carriers of COVID-19 may not show symptoms but may still be highly contagious. I understand that due to the unknowns of this virus, the number of other patients that have been in the practice and the nature of the procedures performed here, that I have an increased risk of contracting the virus by being in any medical or dental facility. I understand that all travelers arriving from a country or region with widespread ongoing transmission, as outlined by the CDC, should stay home for 14 days to practice social distancing and monitor their health after their arrival.
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F nameDOB 00/00/0000L nameNoYesYesNo***Wearing a face mask in any public space is advised. .During the Covid-19 pandemic a $12 PPE (required by health officials) fee will be added to your visit .