Craig E. Ball, DMD
Andrea L. Ball, DMD
Gary C. Ball, DMD
Lalaine Y. Smith, DDS
Bret A. Weathers, DDS
Chad A. Canal, DDS

North

2935 E. 96th Street, Suite 100

Indianapolis, IN 46240

317-846-3463

East

4130 E. 10th Street

Indianapolis, IN 46201

317-359-7244

COVID-19 Pandemic Dental Treatment Consent Form

Dear Patient:

You have presented 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:

PLEASE ANSWER “YES” OR “NO” TO THE FOLLOWING QUESTIONS:

Are you awaiting the results of a COVID-19 test?
Have you had contact with any confirmed COVID-19 positive patients?
Have you had a fever recently?
Have you had shortness of breath or difficulties breathing?
Do you have a cough?
Do you have other flu-like symptoms, such as gastrointestinal upset, diarrhea, headache or fatigue?
Have you travelled to any foreign country or any regions affected by COVID-19 in the last 14 days?