403 East First Avenue, Shakopee, MN 55379

riverrockdds@gmail.com

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Office Hours

Monday	8:00 a.m. – 5:00 p.m.
Tuesday	8:00 a.m. – 5:00 p.m.
Wednesday	8:00 a.m. – 5:00 p.m.
Thursday	8:00 a.m. – 5:00 p.m.
Friday	8:00 a.m. – 3:30 p.m.

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Home COVID‐19 PANDEMIC ‐ PATIENT DISCLOSURES FORM

COVID‐19 PANDEMIC ‐ PATIENT DISCLOSURES FORM

Order Number

This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID‐19 virus.
A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID‐19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us.

It is also important that you disclose to this office any indication of having been exposed to COVID‐19, or whether you have experienced any signs or symptoms associated with the COVID‐19 virus.

Do you have a fever or above normal temperature? *

YES NO

Have you experienced shortness of breath or had trouble breathing? *

YES NO

Do you have a dry cough? *

YES NO

Do you have a runny nose? *

YES NO

Have you recently lost or had a reduction in your sense of smell? *

YES NO

Do you have a sore throat? *

YES NO

Have you been in contact with someone who has tested positive for COVID‐19? *

YES NO

Have you tested positive for COVID‐19? *

YES NO

Have you been tested for COVID‐19 and are awaiting results? *

YES NO

Have you traveled outside the United States by air or cruise ship in the past 14 days? *

YES NO

Have you traveled within the United States by air, bus or train within the past 14 days? *

YES NO

If you answered YES to any of these, please explain.

Explanation

First Name *

Last Name *

Phone *

Email Address *

I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.

Date *

RiverRock Dental in Shakopee, MN is a multi specialty dental clinic. Our dentists, Dr. Todd Christianson and Dr. Andrew Backes hold over a decade of collective clinical expertise to provide quality specialized dental care at affordable price. Each member of our team is dedicated to ensuring that our patients are well-informed and comfortable at all times. At RiverRock Dental, we will never begin a treatment or procedure until all of your questions have been answered and you feel relaxed and at ease. To give you the best possible services and results, we are committed to continual education and learning. Being member of various dental association’s helps us to stay abreast of the changes and recommendations for our profession.

RiverRock Dental in Shakopee, MN is a multi specialty dental clinic. Our dentists, Dr. Todd Christianson and Dr. Andrew Backes hold over a decade of collective clinical expertise to provide quality specialized dental care at affordable price. Each member of our team is dedicated to ensuring that our patients are well-informed and comfortable at all times. At RiverRock Dental, we will never begin a treatment or procedure until all of your questions have been answered and you feel relaxed and at ease. To give you the best possible services and results, we are committed to continual education and learning. Being member of various dental association’s helps us to stay abreast of the changes and recommendations for our profession.

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Our Contact Information

403 East First Avenue, Shakopee, MN 55379
Get directions on the map
(952)445-5556
FAX (952)445-3017
riverrockdds@gmail.com

Copyright © 2021 RiverRock Dental

For emergency cases 1-800-267-0000