COVID-19 SCREENING & CONSENT FORM

If you have been exposed to a communicable disease, you may spread the disease to the dentists, orthodontists, members of their dental team, or other patients/parents in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission:  

 

Have you, your child, or others accompanying you to today’s appointment or other recent acquaintances tested positive for or been diagnosed as having COVID-19 or any other communicable disease? 

Do you, your child, or others accompanying you to today’s appointment or other recent acquaintances have:  

A Fever (defined as above 99.6 degrees)
A Cough?
Stomach or other Gastrointenstinal issues?
Shortness of Breath and/or Trouble Breathing
Persistent Pain, Pressure, or Tightness in the Chest?

By checking this box I certify that I understand that if the answer to any of these questions is yes, I will be asked to reschedule today’s dental or orthodontic appointment.  

Dental and Orthodontic Treatment in the Era of COVID-19

Parent/Patient Signature

PHONE
(847) 869-5417
(847) 869-5509 FAX

LOCATION

One Rotary Center
1560 Sherman Avenue, Ste. 610
Evanston, Illinois 60201

HOURS

Mondays, Wednesdays & Thursdays:
7:30 AM — 5:00 PM
Tuesdays: 8:30 AM — 5:00 PM
Fridays: 7:30 AM — 2:00 PM

Saturdays : 8:30 AM — 3:00 PM

Copyright © 2020: All Rights Reserved: North Shore Dentistry for Children