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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:-------------

Section Two

Drivers License Number

Nearest relative not living with you

Employer / Business

Personal Payment Type

Cash Check Credit Card

In case of emergency

Contact:

Phone / Relation

Who will be responsible for your account?

Father Mother Self Spouse Other

Who will be responsible for your account

Name / SSN

Birth date / Age

Phone / Drivers license

Address

Employer / Business

Spouse or other guarantor information (if different from above)

Spouse or other guarantor

Birth Date / Social Security Number

Address

Employer / Business

Are you a student?

Full-time Part-time Not a student

School Information

School Name

School Address

Primary Insurance Information

Insurance Type:

Dental Medical

Employer / Business

Business Address

City / State / Zip

Phone Number

Plan Name

Insurance Co Name

Policy I.D. Number

Insurance Co Address

City / State / Zip

Phone Number

Group

Insured Party

Relation / Birth Date

Insured Party Sex

Male Female

Insured Party Address

City / State / Zip

Phone / SSN#

Secondary Insurance Information

Insurance Type:

Dental Medical

Employer / Business

Business Address

City / State / Zip

Phone Number

Plan Name

Insurance Co Name

Policy I.D. Number

Insurance Co Address

City / State / Zip

Phone Number

Group

Insured Party

Relation / Birth Date

Insured Party Sex

Male Female

Insured Party Address

City / State / Zip

Phone / SSN#

Dental Information

Reason for today’s visit

Are you in pain?

Yes No

For how long?

Women: Are you?

Pregnant / trying to get pregnant

Yes No

Taking oral contraceptives

Yes No

Nursing

Yes No

Have you ever had any serious illness not listed above?

Yes No

Comments

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:-------------

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

Section Two

In case of emergency

Insurance Information

General Insurance Information

Who will be responsible for your account

Spouse or other guarantor information (if different from above)

School Information

Primary Insurance Information

Secondary Insurance Information

Dental Information

Dental Information

Please indicate any of the following problems by clicking "yes" on the corresponding question

Medical History

Medical History

Women: Are you?

Are you allergic to the following?

Do you have, or have you had, any of the following?

Comments

Conclusion

Verification

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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

Section Two

In case of emergency

Insurance Information

General Insurance Information

Who will be responsible for your account

Spouse or other guarantor information (if different from above)

School Information

Primary Insurance Information

Secondary Insurance Information

Dental Information

Dental Information

Please indicate any of the following problems by clicking "yes" on the corresponding question

Medical History

Medical History

Women: Are you?

Are you allergic to the following?

Do you have, or have you had, any of the following?

Comments

Conclusion

Verification

Click to Sign

Click to Sign

Click to Sign

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.

This form requires that you disable private browsing to continue. Please open a new browser window and reload the form.

This form requires that you disable private browsing to continue.
Please open a new browser window and reload the form.