Appointment Request, Kingsway Dental Patient Registration, Treatment Consent and Affirmation Regarding COVID-19 | Kingsway Dental

  1. { binding displayValue, mode=oneTime }

Appointment Request

This is not an appointment confirmation. We will contact you regarding your requested appointment date and time.

Patient Information

Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Parent Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

FORMAT: MM/DD/YYYY. EX: 06/24/2015

{ binding firstError.message }
Male or Female? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
If you do not know your ID number, please choose accordingly. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Are you a current patient? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Appointment Information

{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{# pageNumbers}

Patient Registration Information

Parent/Guardian Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Employer Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

FORMAT: MM/DD/YYYY. EX: 06/24/2015

{ binding firstError.message }
{ binding firstError.message }
Child's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

FORMAT: MM/DD/YYYY. EX: 06/24/2015

{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Does your child have or previously had any of the following? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
I give Kingsway Dental permission to perform dental treatment on my child. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
I consent to receiving appointment reminders and patient registration requests via email or text. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
I understand that only one parent or guardian is to accompany a child or children for their family appointment. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Kingsway Dental Consent for Treatment

1. I give permission for Kingsway Dental to provide dental services for me or my child.

2. I hereby authorize doctor or designated staff to take x-ray, study models, photographs, and other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of dental needs for the patient named below.

3. Upon such diagnosis, I authorize doctor to perform all recommended treatment agreed upon by me and to employ such assistance as required to provide care.

4. I give consent to the doctor's or designated staffs use and disclosure of any oral, written or electric health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and dental care. I understand that only the minimum amount of information necessary to provide quality care will be used or disclosed and that a notice fully outlining the protection of my personal health information is available.

Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

I acknowledge that I have read and understand these statements with my signature below.

{ binding firstError.message }
{ binding firstError.message }

Kingsway Dental Treatment Consent and Affirmation Form Regarding COVID-19

1. I knowingly and willingly consent to dental treatment at Kingsway Dental by any designated associates or employees during the reopening phase of COVID-19.

2. I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms yet are still highly contagious. It is impossible to determine who has COVID-19 and who does not given the current limitations and availability in COVID-19 viral testing.

3. Risk of transmission: I understand that due to the frequency of visits of other care dental patients, characteristics of the virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the virus simply by being in a dental office, even though standard precautions are being observed.

4. I am unaware of being a possible carrier or infected: I confirm that I have not tested positive for COVID19 in the last 30 days and that I am not presenting with any of the following:

Fever of 100.4 degrees Fahrenheit or 37 degrees Celsius of higher {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Shortness of Breath {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Dry Cough {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Runny Nose {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Sore Throat {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Diminished sense of taste or smell {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Do you have sneezing, watery eyes, and/or sinus pain/pressure unrelated to seasonal allergies? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Have you experienced headaches, fatigue, or weakness? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Are you currently awaiting the results of a COVID-19 test? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Within the last 14 days, have you traveled to any foreign country? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Within the last 14 days, have you traveled within the United States? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

5. Contact with infected: I confirm that I have not knowingly been in close contact (defined as 6 feet or less for a duration of fifteen minutes or more) with someone who has tested positive for COVID-19 in the last 14 days, or with anyone that has had the above stated symptoms in paragraph 4 (#4) in the last 14 days.

6. Public travel: I confirm that I have not traveled outside of the United States in the past 14 days. I confirm that I have not traveled domestically by commercial airline, bus, or train within the last 14 days.

7.  If I receive an appointment time, and by or on the day of my appointment the answer to any of these above questions change or I experience any of the above mentioned symptoms, I will immediately alert office staff to reschedule an appointment at a suitable time.

INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the risks of contracting COVID-19 from the dental office and dental procedures. I reaffirm that I am not a carrier of COVID-19 nor infected with COVID-19 to the best of my knowledge. I voluntarily assume any and all medical/dental risks, including the substantial and significant risk of serious harm, if any, which may be associated with any phase of my treatment as a result of the COVID-19 pandemic. I acknowledge that the nature and purpose of the dental procedures recommended under the current circumstances and restrictions have been explained to me and that I have been given the opportunity to ask questions.

Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{# pageNumbers}

Appointment Request, Kingsway Dental Patient Registration, Treatment Consent and Affirmation Regarding COVID-19 | Kingsway Dental

Appointment Request, Kingsway Dental Patient Registration, Treatment Consent and Affirmation Regarding COVID-19 | Kingsway Dental

Appointment Request

This is not an appointment confirmation. We will contact you regarding your requested appointment date and time.

Patient Information

Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Parent Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Email Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Patient Birthdate ​​[FOR AGES 3-17​] {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Choose Your Insurance Provider {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Male or Female? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
If you chose "Other" for your insurance provider, please list below: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
ID Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
If you do not know your ID number, please choose accordingly. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Insurance Provider Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Are you a current patient? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

Appointment Information

Describe the nature of your appointment: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
If you chose "Other" for the nature of your appointment, please describe: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Patient Registration Information

Parent/Guardian Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Employer {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Employer Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Subscriber Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Last Four (4) Digits of Subscriber's Social Security Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Who will pay this account? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Child's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Birthdate ​​[FOR AGES 3-17​] {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Last Medical Exam {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Physician's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Reason for Appointment {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Does your child have or previously had any of the following? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
If your child has any allergies not listed above, please list: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
If your child is taking any medicine, please list: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Are there any other health conditions not listed above which we should be aware of? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
I give Kingsway Dental permission to perform dental treatment on my child. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
I consent to receiving appointment reminders and patient registration requests via email or text. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
I understand that only one parent or guardian is to accompany a child or children for their family appointment. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

Kingsway Dental Consent for Treatment

1. I give permission for Kingsway Dental to provide dental services for me or my child.

2. I hereby authorize doctor or designated staff to take x-ray, study models, photographs, and other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of dental needs for the patient named below.

3. Upon such diagnosis, I authorize doctor to perform all recommended treatment agreed upon by me and to employ such assistance as required to provide care.

4. I give consent to the doctor's or designated staffs use and disclosure of any oral, written or electric health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and dental care. I understand that only the minimum amount of information necessary to provide quality care will be used or disclosed and that a notice fully outlining the protection of my personal health information is available.

Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Today's Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

I acknowledge that I have read and understand these statements with my signature below.

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Kingsway Dental Treatment Consent and Affirmation Form Regarding COVID-19

1. I knowingly and willingly consent to dental treatment at Kingsway Dental by any designated associates or employees during the reopening phase of COVID-19.

2. I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms yet are still highly contagious. It is impossible to determine who has COVID-19 and who does not given the current limitations and availability in COVID-19 viral testing.

3. Risk of transmission: I understand that due to the frequency of visits of other care dental patients, characteristics of the virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the virus simply by being in a dental office, even though standard precautions are being observed.

4. I am unaware of being a possible carrier or infected: I confirm that I have not tested positive for COVID19 in the last 30 days and that I am not presenting with any of the following:

Fever of 100.4 degrees Fahrenheit or 37 degrees Celsius of higher {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Shortness of Breath {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Dry Cough {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Runny Nose {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Sore Throat {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Diminished sense of taste or smell {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Do you have sneezing, watery eyes, and/or sinus pain/pressure unrelated to seasonal allergies? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Have you experienced headaches, fatigue, or weakness? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Are you currently awaiting the results of a COVID-19 test? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Within the last 14 days, have you traveled to any foreign country? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Within the last 14 days, have you traveled within the United States? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

5. Contact with infected: I confirm that I have not knowingly been in close contact (defined as 6 feet or less for a duration of fifteen minutes or more) with someone who has tested positive for COVID-19 in the last 14 days, or with anyone that has had the above stated symptoms in paragraph 4 (#4) in the last 14 days.

6. Public travel: I confirm that I have not traveled outside of the United States in the past 14 days. I confirm that I have not traveled domestically by commercial airline, bus, or train within the last 14 days.

7.  If I receive an appointment time, and by or on the day of my appointment the answer to any of these above questions change or I experience any of the above mentioned symptoms, I will immediately alert office staff to reschedule an appointment at a suitable time.

INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the risks of contracting COVID-19 from the dental office and dental procedures. I reaffirm that I am not a carrier of COVID-19 nor infected with COVID-19 to the best of my knowledge. I voluntarily assume any and all medical/dental risks, including the substantial and significant risk of serious harm, if any, which may be associated with any phase of my treatment as a result of the COVID-19 pandemic. I acknowledge that the nature and purpose of the dental procedures recommended under the current circumstances and restrictions have been explained to me and that I have been given the opportunity to ask questions.

Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Today's Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }