My dentist has advised me of how her office is taking appropriate precautions during this pandemic. I fully understand  that when I come to be seen at the office, despite these efforts, there may still be risks of me becoming infected with COVID 19.


  • I have had an opportunity to ask questions, and received satisfactory answers to my questions. I understand that if I have concerns about being immunocompromised, I can call my dental office before making an appointment.
  • I fully understand the risks, benefits and alternatives and I have agreed to assume the risks of coming to the office and undergoing a procedure during the COVID-19 pandemic.


  • I understand and agree that the procedure may have to be delayed or cancelled due to my illness or that of the staff or dentist, until such time as it is deemed to be reasonable and safe.