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}

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

{binding displayValue}

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

{binding displayValue}

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

{binding displayValue}

Patient Birthdate [FOR AGES 3-17] {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Male or Female? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If you chose "Other" for your insurance provider, please list below: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

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

{binding displayValue}

If you do not know your ID number, please choose accordingly. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Insurance Provider Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you a current patient? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Appointment Information

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

{binding displayValue}

Patient Registration Information

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

{binding displayValue}

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

{binding displayValue}

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

{binding displayValue}

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

{binding displayValue}

Subscriber Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Last Four (4) Digits of Subscriber's Social Security Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Who will pay this account? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

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

{binding displayValue}

Birthdate [FOR AGES 3-17] {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Last Medical Exam {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

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

{binding displayValue}

Reason for Appointment {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Does your child have or previously had any of the following? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If your child has any allergies not listed above, please list: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If your child is taking any medicine, please list: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are there any other health conditions not listed above which we should be aware of? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

I give Kingsway Dental permission to perform dental treatment on my child. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

I consent to receiving appointment reminders and patient registration requests via email or text. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

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 displayValue}

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

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

{binding displayValue}

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}

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

{binding displayValue}

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

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

Shortness of Breath {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

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

{binding displayValue}

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

{binding displayValue}

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

{binding displayValue}

Diminished sense of taste or smell {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you have sneezing, watery eyes, and/or sinus pain/pressure unrelated to seasonal allergies? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Have you experienced headaches, fatigue, or weakness? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are you currently awaiting the results of a COVID-19 test? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Within the last 14 days, have you traveled to any foreign country? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Within the last 14 days, have you traveled within the United States? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

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}

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

{binding displayValue}

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