239-334-2242 sbennettdmd@gmail.com

New Patient Forms

Pre-appointment Screening and Informed Consent

SUPPLEMENTAL

INFORMED CONSENT

Dental Treatment in the Era of COVID-19

Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as the “Coronavirus,” at any time or any place. Be assured that we always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so.

Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at the gym, grocery store, or favorite restaurant.

“Social Distancing” nationwide has reduced the transmission of the Coronavirus. Although we have taken measures to provide social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, dentist, dental staff and sometimes other patients at all times.

Although exposure is unlikely, do you accept the risk and consent to treatment?

Consent Certification

11 + 11 =

Pre-Appointment Health Screening

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?

Are you/they having shortness of breath or other difficulties breathing?

Do you/they have a cough?

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Have you/they experienced recent loss of taste or smell?

Are you/they in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Is your/their age over 60?

Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

Certification

14 + 7 =

Get In Touch

Call

(239) 334-2242

Address

8900 Gladiolus Dr.
Fort, Myers FL 33908

Hours

Mon - Thurs: 8am - 5pm