Select the appropriate answer for each question below
Travel outside of your home city:
Please list all locations the patient or others living in the patients home have visited within the last 30 days outside of the patient's home city:
By signing below, I acknowledge that there is increased risk for the spread of COVID-19 in a dental office, and that I consider this surgery a necessary procedure for my child. I understand the risk of me or my child being potentially exposed to COVID-19 while at the dental office, and I voluntarily assume that risk. I further understand that I have the right to reschedule the surgery for a later date if I have any concerns about the necessity of the surgery or risk for me or my child being potentially exposed to COVID-19.
I acknowledge that if my child presents the day of surgery with any symptoms of COVID-19, or has possible contact with someone who has COVID-19, surgery will be rescheduled for a later date.
I further acknowledge that I am the parent or legal guardian of the patient named above.