Patient Advisory & Acknowledgement

Receiving dental treatment during Covid19 pandemic

 

You have come to our office today for a routine dental evaluation and/or treatment that will be done during the COVID-19 pandemic. Please be advised of the following:

While our office complies with State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees.

Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge.

In order to reduce the risk of spreading COVID-19, we have asked you a number of “screening” questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.

Please answer the following questions: *

Have you been diagnosed with Covid-19 in the past two weeks?

Are you currently awaiting the results of a COVID-19 test?

Have you traveled outside of Illinois in the past 2 weeks?

Have you been in contact with anyone who has been diagnosed with Covid-19 in the past two weeks?

Do you have a fever?

Do you have any flu like symptoms including body aches, chills, vomiting or diarrhea?

Do you have any shortness of breath?

Do you have a dry cough?

Do you have a runny nose?

Do you have a sore throat?

Do you have sneezing, watery eyes, and/or sinus pain/pressure that is UNUSUAL and NOT related to seasonal allergies?

Have you experienced headaches, fatigue or weakness?

Have you lost your sense of taste and/or smell?

Address

301 N White St, Suite BB, Frankfort, IL 60423, USA

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