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]
    Rated 5/5 based on 37 customer reviews on Google
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    All rights reserved.