Please take a moment to fill out our online COVID-19 Screening Questionnaire and Consent form within 24 hours of your visit. This is mandatory prior to you receiving treatment. All information is kept completely confidential. If this form is completed more than 24 hours before your visit, you will be asked to complete it again.
Consent and Risk Acceptance
I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.
I understand that dental procedures create water spray which is one way that the novel coronavirus can spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus. I understand that due to the frequency of visits of other dental patients, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have an elevated risk of contracting the novel coronavirus simply by being in a dental office.
I understand that Cypress Dental has taken all reasonable steps to decrease and minimize my risk of exposure to the COVID-19 virus. In spite of these steps taken, I understands that there is no way to fully eliminate the risk of viral transmission. I further understand that the nature of dental treatment means that physical distancing is not possible when being treated.
I understand that staying home and/or utilizing Telehealth (virtual or phone consultations) is still the safest option for reducing the risk of COVID-19 transmission.
Please check the box of your chosen answer. ALL questions must be answered. ** If you answer YES to any of the questions, please provide us more detail in the space to the right of your answer.
Are you currently presenting with any of the following symptoms:
Office Policy for COVID-19