DIGI Search Smiles, DDS
COVID-19 Form

6672 N Northwest Hwy
Chicago, IL 60631

P: (855) 444-1715

COVID-19 Dental Treatment Screening Questionnaire & Consent

If you have been exposed to a communicable disease, you may spread the disease to the dentist, dental staff, or other patients in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission:

1. About You

2. COVID-19 Screening Questionnaire

3. Authorization and Consent

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 “Coronavirus”, at any time or in any place. Be assured that we have always followed the CDC, OSHA, and State guidelines. We practice universal precaution and disinfection protocols to limit the transmission of all diseases in our office.

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 your gym, grocery store or favorite restaurant.

I understand that 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 on virus testing.

I knowingly and willingly consent to have dental treatment during the COVID-19 pandemic. I do hereby acknowledge the health risks of the COVID-19 virus and authorize ((DENTALPRACTICE)) to perform any necessary dental treatment.