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:

While our office complies with State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees.
Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge.
I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and may still be highly contagious. It is impossible to determine who does and does not have it given the current limitations in virus testing.
I understand that the CDC recommends social distancing of at least 6 feet and this is not possible with dentistry.

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

Are you awaiting the results of a COVID-19 test?

Yes

Have you had contact with any confirmed COVID-19 positive patients?

Yes

Have you had a fever recently?

Yes

Have you had shortness of breath or difficulties breathing?

Yes

Do you have a cough?

Yes

Do you have other flu-like symptoms, such as gastrointestinal upset, diarrhea, headache or fatigue?

Yes

Have you travelled to any foreign country or any regions affected by COVID-19 in the last 14 days?

Yes

IF SO, WHERE?

PATIENT/RESPONSIBLE PARTY

DATE

PATIENT NAME

WHICH LOCATION WILL YOU BE VISITING

Patient Validation:

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