COVID-19 PANDEMIC DENTAL TREATMENT NOTICE AND ACKNOWLEDGEMENT OF RISK CONSENT FORM
Our goal is to provide a safe environment for our patients and staff, and to advance the safety of our local communities. This document provides information that we ask you read, acknowledge and understand regarding COVID-19.
 
The COVID-19 virus is a serious and highly contagious disease. The World Health Organization has classified it as a pandemic. You could contract COVID-19 from a variety of sources. Our practice wants to ensure you are aware of the additional risks of contracting the virus while receiving dental care.
 
The COVID-19 virus has a long incubation period. You or your health care providers may have the virus and not show symptoms, yet still be highly contagious. Determining who is infected by COVID-19 is challenging and complicated due to limited availability of testing.
 
Due to 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. 
 
You cannot wear a protective mask over your mouth to prevent infection during treatment as your health care providers need access to your mouth to render care. This leaves you vulnerable to COVID-19 transmission.
 
By signing below, you acknowledge that you understand the risk of being in the Dental Depot as it is presented to you and you consent to having dental treatment completed.