05/16/2020
COVID-19 Pandemic Notice and Acknowledgement of Risk Form and Office Protocols
With the presence of COVID-19 globally and locally, our office has been working diligently since the outbreak to ensure for the optimal safety of our staff, patients, and families, and community.
Due to added layers of safety and protection for our patients, staff, families, and community, there is a $10 PPE (Personal Protective Equipment) fee for each patient visit, payable at the time of the appointment until further notice.
First and foremost, if you are experiencing any of the symptoms or conditions listed below, please DO NOT come to your scheduled dental appointment.
Fever
Shortness of breath
Dry cough
Runny nose
Sore throat
Body aches
Chills
Repeated shaking with chills
It is IMPERATIVE that you call your medical care professional in order to have the appropriate diagnostic testing and evaluation performed to indicate if you are infected with COVID-19.
If you are negative for all of the aforementioned conditions, please remain in your vehicle once you arrive at our office. Our waiting room is closed so please call 570-622-3437 to notify us of your arrival and we will es**rt you in.
Only the scheduled patient is es**rted into the office with the exception of a child being allowed one parental or adult es**rt.
The following is the COVID-19 Consent to Treatment Form which is signed at all appointments for review:
I, _____________________________________________________
Knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.
I understand that the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing.
Dental procedures create water spray which is how the disease spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the COVID-19 virus.
I understand the additional safety measures taken are for the safety of the patients, staff, families, and community and agree to the $10 PPE fee payable at the time of the appointment
(initial)_________
I understand due to the frequency of visits of other dental patients, the characteristics of the virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the virus simply by being in a dental office (initial)________
I have been made aware of the CDC, ODA, and ADA guidelines that under the current pandemic all non-urgent dental care is not recommended. Dental visits should be limited to the treatment of pain, infection, conditions that significantly inhibit normal operation of teeth and mouth, and issues that may cause anything listed above within the next 3-6 months. (Initial)___________
I confirm I am seeking treatment for a condition that meets these criteria. (initial)__________
I confirm that I am not presenting with any of the following symptoms of COVID-19 listed below: fever, shortness of breath, dry cough, runny nose, sore throat, body aches, chills, repeated shaking with chills (initial)___________
I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. The CDC recommends social distancing of at least 6 feet away, and this is not possible for the dental visit (initial)_________
I verify that I have not traveled outside the United States in the past 14 days to countries that have been affected by COVID-19 (initial)__________
I verify that I have not traveled domestically within the United States by commercial airline, bus, or train within the past 14 days. (initial)___________
Please Note: if you have either been furloughed or placed on unemployment compensation, your dental benefits could have been terminated, suspended, or changed. All patients are responsible for their financial balances, even if insurance does not reimburse for their treatment. ALL patients are responsible to know and understand their insurance coverage situation at the time of treatment.
Name/Signature_____________________________________________
Date ______________________________________________________
Joseph Chipriano, DMD
2000 W Market St.
Pottsville, PA 17901
570-622-3437
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