COVID-19 Pandemic Dental Treatment Consent Form


Even after following protocols set by the American Dental Association and our state’s dental association, it is still possible to contract COVID-19 while at a dental office. We are following all guidelines to minimize the risk of transmission. I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic. I understand that the COVID-19 virus has a long incubation period during which carriers of this virus may not show symptoms and may still be highly contagious.   I understand that – due to the frequency of visits of other dental patients, the characteristics of the COVID-19 virus, and the characteristics of dental procedures – I have an elevated risk of contracting the COVID-19 virus simply by being in a dental office.   I confirm that I am not presenting any of these COVID-19 symptoms: Fever Shortness of breath Dry cough Runny nose (not associated with seasonal allergies) Sore throat  I confirm that I have not been in contact with a person who has been diagnosed with COVID19 within the past 14 days.   I understand that air travel significantly increases my risk of contracting and transmitting theCOVID-19 virus. And the CDC recommends social distancing of at least six feet for a period of 14 days to anyone who has recently traveled, and this is not possible with dentistry.   I verify that I have not traveled outside the United States in the past 14 days.   I verify that I have not traveled domestically within the United States by commercial airline, bus or train within the past 14 days.   Printed name:   Date of birth:  

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Signature Certificate
Document name: COVID-19 Pandemic Dental Treatment Consent Form
lock iconUnique Document ID: 7c08534ad45121c301f8358f4b7961b1c01fc69c
Timestamp Audit
August 4, 2020 3:22 pm EDTCOVID-19 Pandemic Dental Treatment Consent Form Uploaded by david Levine - david@godentalbrands.com IP 172.72.52.26
August 4, 2020 3:24 pm EDTFront Desk - jwinder@goclearortho.com added by david Levine - david@godentalbrands.com as a CC'd Recipient Ip: 174.247.17.134
August 4, 2020 3:24 pm EDTDavid Levine - david@godentalbrands.com added by david Levine - david@godentalbrands.com as a CC'd Recipient Ip: 174.247.17.134