Greenfield, Salinas & La Ceyba Dental

COVID-19 Pandemic - Patient Disclosure
PANDEMIA DE COVID-19 – INFORMACION PARA EL PACIENTE

This patient disclosure from seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID-19 virus.

Este cuestionario busca informacion de usted para poder considerar el mejor tratamiento y hacer decisiones mientras que estamos en la pandemia.

A weak or compromised immune system (including, but not lmited 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.

Cuando su salud esta debilitada (con condiciones como diabetes, asma, COPD, tratamiento para cancer, radiacion, quemoterapia, y otros tipos de enfermedades debilitantes), pueden ponerlo a mas riesgo de contraer COVID-19. Favor de dicernos de cualquier condicion que pueda comprometer su sistema inmunitario. Tiene que entender que podemos cambier su cita dependiendo de sus respuestas.

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

Tambien es importante que nos diga si ha sido expuesto a COVID-19 o si ha experienciado algunos sintomas o señales asociados con el virus COVID-19.

Do you have a fever or above normal temperature higher than 99.5 F?
Tiene usted alta temperatura (mas de 99.5 F) o fiebre?
Have you experienced shortness of breath or had trouble breathing?
Ha experienciado problemas respiratorios o trabajo respirando bien?
Do you have a dry cough?
Tiene tos seca?
Do you have a runny nose?
Tiene secreción nasal?
Have you recently lost or had a reduction in your sense of smell or taste?
Tiene problema con el sentido de oler o sabor?
Do you have a sore throat?
Le duele la garganta?
Do you have chills?
Sufre de escalofrios?
Do you have severe muscle pain?
Tiene usted severos Dolores de musculos?
Do you suffer from recent headaches?
Tiene usted nuevos Dolores de cabeza?
Have you been in contact with someone who has tested positive for COVID-19?
Es estado en contacto con alguien que probo positivo al virus COVID-19?
Have you tested positive for COVID-19?
Ha usted probado positivamente al virus COVID-19?
Have you been tested for COVID-19 and are awaiting results?
Le acaban de probar para ver si tiene el virus COVID-19 y esta esperando por los resultados??
Have you traveled outside the United States by air or cruise ship in the past 14 days?
Ha viajado fuera de los Estados Unidos por avion o barco en los ultimos 14 dias?
Have you traveled within the United States by air, bus, or cruise ship within the past 14 days?
Ha viajado a un estado fuera de California por avion, autobus, carro o tren Durante los ultimos 14 dias?

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.

Yo entendi y respondi correctamente la informacion de arriba y entiendo los riesgos y precauciones hacerca de el tener un sistema debil me puede hacer mas susceptible al virus COVID-19 Y le he dejado saber la verdad hacerca de mi salud.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.
Al firmar este documento, yo confirmo que mis respuestas son correctas y verdaderas