I confirm that I am not presenting any of the following symptoms of COVID-19 listed below:

FEVER (feeling hot to touch, a temperature of 100 degrees Fahrenheit or higher)
CHILLS
COUGH that's new or worsening (continuous, more than usual)
BARKING COUGH, making a whistling noise when breathing ('CROUP')
SHORTNESS OF BREATH (out of breath, unable to breathe deeply)
SORE THROAT
DIFFICULTY SWALLOWING
RUNNY NOSE (not related to seasonal allergies or other know causes or conditions)
NASAL CONGESTION (not related to seasonal allergies or other known causes or conditions)
LOSS OF SENSE OF SMELL
PINK EYE (conjunctivitis)
HEADACHE that's unusual or long-lasting
DIGESTIVE ISSUES (nausea/vomiting, diarrhea, stomach pain)
MUSCLE ACHES
EXTREME TIREDNESS THAT IS UNUSUAL (fatigue, lack of energy)
FALLING DOWN MORE THAN USUAL
FOR YOUNG CHILDREN & INFANTS: Sluggishness or lack of appetite

I verify that I have not traveled outside of United States in the past 14 days and have not been in touch with anyone with covid/potential covid in the last 14 days.

I, knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.

Thank you for doing your part in keeping everyone safe. Please note the following:

wear a MASK when entering the dental office
SANITIZE your hands immediately upon arrival
maintain Social Distancing from other patients
have your Temperature taken by our team members
not have any Accompaniment except small child/caregivers/translators

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