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COVID-19 Pandemic Dental Treatment Notice and Acknowledgement of Risk Form

The World Health Organization has characterized the COVID-19 virus, also known as “Coronavirus,” as a pandemic. Our practice wants to ensure you are aware of the risks of exposure to COVID-19 associated with receiving treatment during this pandemic.

COVID-19 is highly contagious and has a long incubation period. You or your healthcare providers may have the virus, not show symptoms and yet still be highly contagious. COVID-19 can result in a life-threatening respiratory disease in some patients. You may be exposed to COVID-19 at any time or in any place. Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office.

Dental procedures can create fine water spray or “aerosols” which may remain in the air for several minutes to hours. These aerosols may contain the COVID-19 virus and may create a risk of COVID-19 exposure. You cannot wear a protective mask over your mouth to reduce exposure during treatment as your healthcare providers need access to your mouth to render care. This leaves you vulnerable to COVID-19 transmission while receiving dental treatment.

To provide a safe environment for our patients and staff, this practice follows the applicable state and federal regulations and protocols for infection control, universal personal protection, and disinfection. However, due to the nature of the procedures we provide, it may not be possible to maintain social distancing between patients, doctors, and staff at all times.

Patient Acknowledgement

I acknowledge that I have read the Notice above and that I understand and accept that there is an increased risk of COVID-19 exposure with treatment during the pandemic.

I understand and accept the increased risk of COVID-19 exposure with treatment at this office.

I also acknowledge that I could, or may have, exposure to COVID-19 from outside this office and unrelated to my visit here.

Signature of patient (Parent or Guardian if Minor)

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Date:-------------

Patient Information

Patients Name

Address

CIty / State / Zip

Home Phone

Work Phone / Cell Phone

Birth date / Sex

M F

Social Security #

Employed by

Occupation

Dentist

Whom may we thank for referring you to us?

Spouse Information

Name of Spouse

Birth Date / Social Security #

Home Phone

Work Phone / Cell Phone

Insurance Information

Dental Insurance Company

Subscriber Name

Identification #

Health History

Family M.D. or Physician

Phone Number:

Are you a cardiac patient? If so please list your cardiologist’s name and phone number:

Have you been a patient in the hospital in the last year?

Have you had excessive bleeding requiring special treatment?

List any medications or drugs you are taking

Do you have a history of a chemical dependency? If yes, how long in recovery?

List all medication allergies.

Latex Allergy?

Is there a chance you could be pregnant?

How far along?

Preferred Pharmacy

Medical History

List any other serious illness you have or had.

Verification

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

I permit the office to communicate with me via text message on my cell phone.

Yes No

Signature of patient (Parent or Guardian if Minor)

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Date:-------------

FEES & PAYMENTS We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs. Signature of patient (Parent or Guardian if Minor)

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Date:-------------

This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me. Signature of patient (Parent or Guardian if Minor)

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Date:-------------

I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice. Signature of patient (Parent or Guardian if Minor)

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Date:-------------

Consent for Treatment

I understand the following:

1.   Endodontics as with any branch of medicine or dentistry is not an exact science. Therefore, no guarantee of treatment success can be given or implied. As a rule, 90% of routine nonsurgical cases, and 75% of surgical cases are successful.

2.   Cases started in other offices or retreatment cases may have a different outcome than expected under optimal conditions.

3.   Proper post-treatment restoration is a necessity. I must contact my referring dentist, after completion of the endodontic therapy to arrange for the permanent restoration within thirty days.

4.   Periodic recall examination is recommended and no further charges are made for it. However, compliance is the responsibility of the patient.

5.   It may be necessary to alter the tooth structure or remove the restoration of the tooth being treated, or go through existing crowns or bridgework.

6.   Possible complications of treatment include, but are not limited to:

a. Procedural difficulties in the course of treatment (Separated instrument, perforation, overfilling, etc.)
b. Fracture of the crown or root
   c. Swelling, pain or discoloration of the soft or hard adjacent tissues
d. Persistent numbness or sinusitis following endodontic surgical treatment.
e. Additional unknown or unspecified problems, the explanation of and the responsibility of which cannot be giving or assumed.
f. Post-surgical infection

7.   Treatment will be performed in accordance with accepted methods of clinical practice. Included in the therapy will be the taking of a minimal number of x-rays as dictated by the course of treatment.

8.   Quoted fees include office visit, treatment, recall appointments, medications and drugs administered at the office.

9.   A charge may be made for additional appointments resulting from the failure of the patient to follow the prescribed treatment schedule.

Signature of patient or legal designate

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Date:-------------

truForm by PBHS

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Covid-19 Questionnaire

Patient Disclosures

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COVID-19 Pandemic Dental Treatment Notice and Acknowledgement of Risk Form

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Demographic Information

Patient Information

Spouse Information

Insurance Information

Insurance Information

Health History

Health History

Check: any of the following that you have or had.

Medical History

Conclusion

Verification

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Consent for Treatment

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Main Header

Covid-19 Questionnaire

Patient Disclosures

Click to Sign

COVID-19 Pandemic Dental Treatment Notice and Acknowledgement of Risk Form

Click to Sign

Demographic Information

Patient Information

Spouse Information

Insurance Information

Insurance Information

Health History

Health History

Check: any of the following that you have or had.

Medical History

Conclusion

Verification

Click to Sign

Click to Sign

Click to Sign

Click to Sign

Consent for Treatment

Click to Sign

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

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