I * at email * consent to receive treatment from Tribeca Advanced Dentistry during the COVID-19 outbreak. I understand there is much to learn about the newly emerged COVID-19, including how it spreads and is 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 during close contacts. I understand that close contact can occur from being within approximately 6 feet of someone with COVID-19 for a 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, and by receiving treatment at, the Practice. I understand that even with the Practice following all the CDC and ADA guidelines for infection control of COVID-19 in providing dental treatments, that I am still at risk for possible infection with receiving such treatment at the Practice at this time PLEASE CHECK HERE: *YESNO. I understand that dental procedures have the potential to include aerosol-generating procedures as well as anticipated splashes and sprays, which are some of the ways that COVID-19 can be spread. I understand that the symptoms listed below are representative of COVID-19: ● Fever ● Dry Cough ● Shortness of Breath ● Temperature ● Persistent pain or pressure in the chest ● Bluish lips or face I confirm that I, and those who live with me, have not displayed, or currently have, any of the symptoms that are representative of COVID-19, which are outlined above PLEASE CHECK HERE: *YESNO I confirm that, to the best of my knowledge, in the past 14 days I have not come into close contact with anyone who appeared to me as displaying, or having, any of the symptoms that are representative of COVID-19, which are outlined above PLEASE CHECK HERE: *YESNO I confirm, to the best of my knowledge, that I have not had close contact with an individual diagnosed with COVID-19 in the past 14 days PLEASE CHECK HERE: *YESNO I would like Tribeca Advanced Dentistry administer an antibody test when I come into the office PLEASE CHECK HERE: *YESNO Prior to the visit, I have measured my temperature which is ENTER HERE: F. I have been tested for COVID-19 and the result was PLEASE CHECK HERE: * NOT TESTEDPOSITIVENEGATIVE on DATE: I have been tested for COVID-19 anti-bodies and the result was PLEASE CHECK HERE: * NOT TESTEDPOSITIVENEGATIVE on DATE: I have symptoms which I want to notify the practice about:
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