Pinali Javeri Menon D.D.S.

2 Sleepy Hollow Road, Edison, NJ 08820

732-516-0111

COVID-19 Emergency Treatment Employee Acknowledgement and Consent Form

As the coronavirus (COVID-19) continues to spread, Smiles 'R' Us Dentistry wants to ensure that you are aware of what steps we are taking to protect both you as an employee as well as our patients.

In order to prevent the spread of COVID-19, please ensure that you follow the guidance listed below:

• Cover your mouth and nose with a tissue or your sleeve (not your hands) when you cough or sneeze;

• Throw all used tissues in the trash right away and wash your hands immediately after handling used tissues;

• Wash your hands immediately before and after the treatment of each patient;

• Avoid touching your eyes, nose or mouth;

• Avoid close contact with people who are sick; and

• Clean and disinfect frequently touched objects and surfaces, such as your keyboard or mouse, countertops and other surfaces in the office and the operatories, including treatment chair arms, etc. with a disinfectant provided by the Practice;

• Follow all other safety protocols, as discussed below, to reduce the risk of infection of the staff and patients from the coronavirus.

In addition, the Practice will take all reasonable means, within the limits of what is available to it, to continue to follow all federal, state and local regulations including, but not limited to, the Center for Disease Control (“CDC”) and Occupational Safety and Health Administration (“OSHA”) guidelines to protect employees and patients during this time.

To the extent that they are available, the Practice will continue to provide staff with personal protective equipment (e.g. masks, gloves and safety glasses) (PPE).

I acknowledge that I will use this PPE in compliance with all infection control guidelines for their use to reduce the risk of infection of staff and patients from the coronavirus.

I acknowledge that the Practice has provided me with the CDC and American Dental Association (“ADA”) guidelines, for infection control of the coronavirus, from the CDC and ADA websites; and that I will follow these guidelines in my providing emergency dental care for any Practice patients.

I acknowledge that the Practice can immediately send me home and take other disciplinary action, up to and including immediate termination, for: (1) any failure to use PPE in accordance with all the infection control guidelines for their use; and (2) any violations of Practice, CDC and/or ADA guidelines for coronavirus infection control in my providing emergency dental care for Practice patients.

I understand that the symptoms listed below are representative of COVID-19:

• Fever

• Dry Cough

• Shortness of Breath

• Temperature

• Persistent pain or pressure in the chest

• Bluish lips or face

I confirm that I, and those who live with me, have not displayed, or currently have, any of the symptoms that are representative of COVID-19, which are outlined above.

I confirm that, to the best of my knowledge, in the past 14 days I have not come into close contact with anyone who appeared to me as displaying, or having, any of the symptoms that are representative of COVID-19, which are outlined above.

I confirm, to the best of my knowledge, that I have not had close contact with an individual diagnosed with COVID-19 in the past 14 days.

I understand that all travelers arriving from a country or region with widespread ongoing transmissions should stay home for 14 days to practice social distancing and monitor their health after their arrival.

I confirm that I, and those who live with me, have not returned in the last 14 days from traveling to any of the countries or regions with widespread ongoing transmissions, including all European countries, China, Korea, and Latin America.

I agree that if I, or anyone who lives with me, does begin to display or is tested positive for the coronavirus; or if I have close contact with anyone who has displayed or is tested positive for the coronavirus; that I will immediately advise the Practice manager and will self-quarantine.

I understand and accept that the Practice has the right to: (1) screen me for symptoms of the coronavirus prior to every shift I work, to protect other staff and patients from possible infection of the coronavirus; and (2) to immediately send me home if I appear to have any symptoms; and (3) to not have me return to work until I am cleared by a physician or other qualified healthcare provider (e.g. advanced practice nurse) to return.

I, (), consent to providing emergency treatment to patients in need during the COVID-19 outbreak. I understand and accept the following: (1) that based on what is currently known about COVID-19, the spread is thought to occur mostly from person-to-person via respiratory droplets when there is close contacts; (2) that close personal contact can occur from being within approximately 6 feet of someone with COVID-19 for a period of time or by having direct contact with infectious secretions from someone with COVID-19; (3) that due to the unknowns of this virus, the number of patients that have been in the practice and the nature of the procedures performed here, I have an increased risk of contracting the virus by being in, and providing treatment at the practice; (4) that dental procedures have the potential to include aerosol-generating procedures as well as anticipated splashes and sprays, which are some of the ways that COVID-19 can be spread; and (5) that even with the use of personal safety equipment and with the following of all CDC and ADA guidelines for infection control by myself and all other staff at the practice, I am still at risk of possible infection with the coronavirus through providing emergency dental care for patients.

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For Practice Use: Signature of Employer

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