Dr. Navneet Rai

180 North Main Street, Milltown, NJ 08850

732-247-3684

COVID-19 Patient Prescreening & Consent Form

Date:
Last Name:
First Name:
MI:
Preferred Name:
Phone:
Mobile:
Work:
Ext:
Best time to call:
Email:
Do you have fever or have you felt hot or feverish recently (14-21 days)?
Are you having shortness of breath or other difficulties breathing?
Do you have a cough?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Have you experienced recent loss of taste or smell?
Are you in contact with any people that have been confirmed COVID-19 positive?
Patient's who are well but have a sick family member at home with COVID-19 should consider postponing elective treatment.
Are you over 60 years old?
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Have you traveled in the past 14 days to any regions affected by COVID-19?
Travel History within United States?
International Travel History?
Did you get test done for Covid-19?
If yes when was the test done date?
Are you still Positive or Negative?
If yes, when did you find out date?
If positive, were you any of the following?
When did you become COVID-19 Negative?
First tested date for COVID-19 Negative? (Please bring the paperwork with you)
Second tested date for COVID-19 Negative? (Please bring the paperwork with you)
COVID-19 Antibodies Testing done?
If yes when was the test done date?
Antibody Present or Not Present date?
Did you attended any protest rally in last two weeks?

Please check the following regarding recent gatherings.





Please give details below such as date, number of people and any other important information. This information is to help us keep our patients safe as well as our staff.

NOTE:

PATIENT CONSENT
SUPPLEMENTAL INFORMED CONSENT:
Dental Treatment in the Era of COVID-19 Patient

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 state and federal regulations and recommended universal personal protection protective equipment (PPE) 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 your 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, dental healthcare team members and sometimes other patients at all times.

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


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