CONSENT FOR EMERGENCY OR URGENT APPOINTMENT DURING COVID-19
Patient's First Name
Patient's Last Name
I knowingly and willingly consent to an in-person dental appointment during the COVID-19 pandemic.
I understand the COVID-19 virus has a long incubation period, during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not, given the current limits in virus testing.
Some dental procedures create water spray or "dental aerosol". It is unclear as to how long the ultra-fine nature of the spray may linger in the air, which can transmite 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 greater risk for contracting COVID‐19.
***Smiles by Delivery uses a 2 part air purification system during the entire appointment, which eliminates pathogens down to 0.125 microns. The first system uses UVC light with its HEPA filter to kill the pathogens and it can purify a 1100 sq ft room in about 20mins. The second system reduces 90% of the dental aerosol produced.***
(initial) I have been made aware of the CDC and ADA guidelines that under the current pandemic, all non-urgent dental care is not recommended. Dental visits should be limited to the treatment of pain, infection, conditions that significantly inhibit normal operation of teeth and mouth, and issues that may cause anything listed above, within the next 3-6 months.
(initial) I confirm I am seeking treatment for a condition that meets these criteria.
I understand that a COVID-19 screening will be required on the day of my appointment, to confirm that I do not present with symptoms or risk for having COVID-10.
Full Name of Responsible Party and Relationship to Patient
Responsible Party Signature
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