Tele-Dentistry    
Our office is open for
Dental Emergencies
and
Tele-Dentistry
is Available.
Call: 212-586-3585

Patient Advisory and Acknowledgment
Receiving Dental Treatment During the COVID-19 Pandemic
 
Dear Patient:

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.

 
  • PATIENT/RESPONSIBLE PARTY
  • DATE:
  • EMAIL ADDRESS:
  • PHONE NUMBER:

PLEASE ANSWER “YES” OR “NO” WITH YOUR INITIALS, TO THE FOLLOWING QUESTIONS:

  • Did you have a confirmed case of COVID-19?
  • Yes No
  • Did you test positive for Covid-19 antibodies?
  • Yes No
  • ARE YOU CURRENTLY AWAITING THE RESULTS OF A COVID-19 TEST?
  • Yes No
  • DID YOU RECEIVE A COVID-19 VACCINE?
  • Yes No
  • DO YOU HAVE A FEVER, SHORTNESS OF BREATH, DRY COUGH, RUNNY NOSE, OR SORE THROAT?
  • Yes No
  • DO YOU HAVE SNEEZING, WATERY EYES, AND/OR SINUS PAIN/PRESSURE THAT IS UNUSUAL AND NOT RELATED TO SEASONAL ALLERGIES?
  • Yes No
  • HAVE YOU EXPERIENCED HEADACHES, FATIGUE, WEAKNESS, OR LOST YOUR SENSE OF TASTE AND/OR SMELL?
  • Yes No
  • WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELLED OUTSIDE OF NYC?
  • Yes No
  • IF SO, WHERE?

Please enter code above in the field below.