COVID-19 Patient Disclosures and Consent

Please complete this form for the patient as well as any parent, guardian, or caretaker needing to accompany the patient in the dental office within 24 hours of your upcoming appointment.

EACH patient needs to have a separate form completed.

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

A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at a 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.
It is also important that you disclose to this office any indication of having been exposed to COVID‐19, or whether you have experienced any signs or symptoms associated with the COVID‐19 virus.
Please notify us if you develop symptoms of, or test positive for, COVID-19 in the next 2 days.

Our goal is to provide a safe environment for our patients and staff, and to advance the safety of our local community. This document provides information we ask you to acknowledge and understand regarding the COVID‐19 virus.

Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office.

Dental procedures create water spray which is one way the disease is spread. The ultra‐fine nature of the water spray can linger in the air for a long time, allowing for transmission of the COVID‐19 virus to those nearby. There may be an increased risk of contracting the COVID‐19 virus in the dental office or with dental treatment.
By signing below I consent to be treated by Orono Dental Care and attest that the answers I have have given to the above questions are true to the best of my knowledge. I confirm that I have read the Notice above and understand and accept that may be an increased risk of contracting the COVID‐19 virus in the dental office or with dental treatment. I understand and accept the additional risk of contracting COVID‐19 from contact at this office. I also acknowledge that I could contract the COVID‐19 virus from outside this office and unrelated to my visit here.