Atlanta Oral & Facial Surgery - Acknowledgement of Risk Form

COVID‐19 PANDEMIC EMERGENCY DENTAL TREATMENT NOTICE AND ACKNOWLEDGEMENT OF RISK FORM

First Name *:

Last Name *:

Date of Birth *:

Phone Number :

Email :

Our goal is to provide a safe environment for our patients and staff, and to advance the safety of our local community. This document provides information we ask you to acknowledge and understand regarding the COVID‐19 virus.

The COVID‐19 virus is a serious and highly contagious disease. The World Health Organization has classified it as a pandemic. You could contract COVID‐19 from a variety of sources. Our practice wants to ensure you are aware of the additional risks of contracting COVID‐19 associated with dental care.

The COVID‐19 virus has a long incubation period. You or your healthcare providers may have the virus and not show symptoms and yet still be highly contagious. Determining who is infected by COVID‐19 is challenging and complicated due to limited availability for virus testing.

Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office.

You cannot wear a protective mask over your mouth to prevent infection during treatment as your health care providers need access to your mouth to render care. This leaves you vulnerable to COVID‐19 transmission while receiving dental treatment.

Pursuant to statements from the Center for Disease Control (CDC) and the American Dental Association (ADA), nonessential or elective treatment, based on the assessment of our staff, will be rescheduled. According to the ADA, dental emergencies are “potentially life threatening and require immediate treatment to stop ongoing tissue bleeding [or to] alleviate severe pain or infection.” The ADA also recommends that urgent dental care which “focuses on the management of conditions that require immediate attention to relieve severe pain and/or risk of infection and to alleviate the burden on hospital emergency departments” be provided in as minimally invasive a manner as possible.

I confirm that I have read the Notice above and understand and accept that there is an increased risk of contracting the COVID‐19 virus in the dental office or with dental treatment. I further confirm I am seeking treatment for a condition that meets the emergent or urgent criteria noted above. I understand and accept the additional risk of contracting COVID‐19 from contact at this office. I also acknowledge that I could contract the COVID‐19 virus from outside this office and unrelated to my visit here.

I have read and understand the information stated above :

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(Your IP Address :IP:216.73.216.88 )

COVID‐19 PANDEMIC EMERGENCY DENTAL TREATMENT NOTICE AND ACKNOWLEDGEMENT OF RISK FORM PREVIEW

First Name :

Last Name :

Date of Birth :

Phone Number :

Email :

I have read and understand the information stated above :

Patient Signature

Dec 14,2025 & ( IP:' 216.73.216.88 ' )

DATE & IP ADDRESS

COVID‐19 PANDEMIC ‐ PATIENT DISCLOSURES PREVIEW

Our practice wants to ensure you are aware of the relative risks of exposure to COVID-19 associated with receiving treatment. This practice has always followed the applicable state and federal regulations and recommendations regarding infection control, sterilization, disinfection, and the use of PPE (personal protective equipment). We also work to protect our patients and office staff from virus spread by promoting frequent hand washing and office cleaning, using PPE for patient encounters, and adding additional environmental controls in the treatment areas Although we are using enhanced infection control measures in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing during treatment or for you to wear a mask during treatment. This means that the risk of exposure to COVID-19 remains when receiving treatment during the pandemic.

COVID Health History
Have you ever been diagnosed with COVID-19?
Have you ever been hospitalized for COVID-19 treatment?
Are you fully vaccinated or in the course of being vaccinated for COVID-19?
Have you been tested for COVID-19 and are awaiting results?
In the last 14 days, have you been in contact with any confirmed cases of COVID19?
COVID Health History
Have you had a fever or felt hot or feverish?	Yes
Have you had any shortness of breath or other breathing difficulties?
Have you had a cough?
Have you had any other flu-like symptoms, such as an upset stomach, headache, or fatigue?
Have you had a loss of taste of smell?
Have you otherwise felt unwell?

Relationship to Patient :

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Patient Acknowledgement - By signing this document, I acknowledge that I have read the Patient Acknowledgment and that I understand and accept that there is a risk of COVID-19 exposure with treatment. I also acknowledge that the Health History and Health Screening answers I have provided are true and accurate

Patient Signature

Dec 14,2025 & ( IP:' 216.73.216.88 ' )

DATE & IP ADDRESS

COVID Health History
Have you ever been diagnosed with COVID-19? * Yes No

Have you ever been hospitalized for COVID-19 treatment? * Yes No

Are you fully vaccinated or in the course of being vaccinated for COVID-19? * Yes No

Have you been tested for COVID-19 and are awaiting results? * Yes No

In the last 14 days, have you been in contact with any confirmed cases of COVID19? * Yes No

Symptoms – Today, or in the last 14 day
Have you had a fever or felt hot or feverish? * Yes No

Have you had any shortness of breath or other breathing difficulties? * Yes No

Have you had a cough? * Yes No

Have you had any other flu-like symptoms, such as an upset stomach, headache, or fatigue? * Yes No

Have you had a loss of taste of smell? * Yes No

Have you otherwise felt unwell? * Yes No