COVID – 19 Protocol Consent

Dear Patient:

We hope  you and your family are  in good health. Our community has been through a lot over the last few months, and all of us are looking forward to resuming our normal routines. While many things have changed, one thing has remained the same: our commitment to your safety.

Here at Confi Dental LLC, we are taking all the necessary precautions that are at our disposal to protect our patients and staff from the spread of infection incompliance with CDC (Centers for Disease Control and Prevention), the ADA (American Dental Association) guidelines and the Governor of Connecticut orders. Please be advised that there may be a risk in being in the proximity of dentists, patients, or staff. We are taking precautions to limit the spread of disease, yet there is still a possibility of transmission. 

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
Are you having cough, shortness of breath or other difficulties breathing?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Have you experienced recent loss of taste or smell?
Are you in contact with any confirmed COVID-19 positive patients?
Is your age over 65? Consent to treat ( High Risk) Y OR N
Do you have heart, lung, kidney disease, diabetes or any auto-immune disorder?
Have you traveled in the past 14 days to any regions affected by COVID-19?