Questionnaire18andOlder - The Dentist for Kids

Patient Name *

First

Last

Patient Date of Birth *

Have you had a cough or fever in the past 2 weeks? *

Yes
No

Have you been exposed to anyone in the past 2 weeks with fever and/or cough? *

Yes
No

Parent’s name and contact number if we need to call: *

First

Last

Any dental problems? *

Yes
No

Please list your dental problems: *

Any specific dental concerns? *

Yes
No

Please describe your dental concerns: *

Any medical changes since last visit? *

Yes
No

Please explain medical changes: *

Any recent hospitalizations? *

Yes
No

Please describe the reasons for your hospitalization: *

Any medications? *

Yes
No

Please list your medications: *

Change of address? *

Yes
No

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Insurance change? *

Yes
No

If your insurance has changed, please present the receptionist with the new insurance information upon checking in, or in advance by phone or email: service@thedentist4kids.com

Assumptions of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19

As you know, the novel Coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization in 2020. COVID-19 is extremely contagious and is believed to spread mainly from person to person contact.

Pediatric Dental Care, LLC, Pediatric Dental Care of Frederick, LLC, and PDC Orthodontics, LLC have put extreme preventive measures in place according to State, CDC, and other health organizations to reduce the spread of COVID-19. However, being in a social setting, will increase the risk of exposure and the spread of COVID-19.

By signing this agreement:

I acknowledge the contagious nature of Coronavirus, COVID-19.
I acknowledge that I have provided accurate health information regarding my child and/or myself with the COVID-19 questionnaire.
I understand that giving false information during the COVID-19 questionnaire will place the staff, who are treating my child or myself, and other patients visiting the premises at risk of being exposed or infected with COVID-19.
I understand that my child and/or I may be exposed to or infected by this virus that may result in personal injury, illness, permanent disability, or death.
I understand that the risk of becoming exposed or infected by COVID-19 may result from the actions of myself, my child/ren, employees, and other patients, and their families.
I voluntarily agree to assume all of the foregoing risks and accept the sole responsibility for any injury related to COVID-19 infection.
I hereby release, covenant not to sue, discharge, and hold harmless Pediatric Dental Care, LLC, Pediatric Dental care of Frederick, LLC, and PDC Orthodontics, LLC, its owners, employees, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto.

Signature *

By signing, I acknowledge that all the information provided on this form is accurate and true to the best of my knowledge.

Patient questionnaire for young adults 18 years and older

Assumptions of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19