Covid-19 questionnaire

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
 *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
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
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
YESNO

I would like Tribeca Advanced Dentistry administer an antibody test when I come into the office
YESNO 

Prior to the visit, I have measured my temperature which is .

I have been tested for COVID-19 and the result was
NOT TESTEDPOSITIVENEGATIVE on 

I have been tested for COVID-19 anti-bodies and the result was
NOT TESTEDPOSITIVENEGATIVE on   

I have symptoms which I want to notify the practice about: 

Tribeca Advanced Dentistry
23 Warren St #10,
New York, NY 10007
212-355-4510
[email protected]
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All rights reserved.