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COVID‐19 PANDEMIC ‐ PATIENT DISCLOSURES

Dental Treatment During COVID-19 Pandemic Consent Form

 

  1. I knowingly and willingly consent to dental treatment.

 

  1. I understand that our office is following CDC and ADA guidelines and recommendations by the Virginia Department of Public Heath to:
  • Screen patients and employees for exposure or infection with COVID-19
  • Use proper personal protective equipment
  • Take measures to reduce aerosol
  • Reduce the amount of patients on premise as well as encourage distancing
  • Continue to diligently disinfect the office regularly and promote use of barriers

 

  1. I understand the COVID-19 virus has a long incubation period during which carriers of

the virus may not show symptoms yet are still contagious. It is impossible to determine who has it and who does not given the current limitations and availability in COVID-19 viral testing. I understand that emergency dental procedures create aerosol (water spray) which is one way the disease is spread. The ultra-fine nature of the spray may linger in the air for hours and facilitate transmission of the COVID-19 virus.

 

  1. Risk of transmission: I understand that due to the nature of dental visits, characteristics of the virus, and the characteristics of dental procedures, that I have a risk of contracting the virus simply by being in a dental office, even though mandates are being observed.

 

  1. I am unaware of being a possible carrier or infected: I confirm that I have not tested positive for COVID-19 in the last 14 days and that I am not presenting with any of the following symptoms of COVID-19:
  • Fever of 100.0 degrees Fahrenheit or 37 degrees Celsius or higher • Shortness of breath • Dry cough • Runny nose • Sore throat • Diminished sense of taste and smell

 

  1. Contact with infected: I confirm that I have not knowingly been in close contact defined as 6 feet or less for a duration of fifteen minutes or more with someone who has tested positive for COVID-19 in the last 14 days, or with anyone that has had the above stated symptoms in the last 14 days.

 

  1. Public travel: I confirm that I have not traveled outside of the United States in the past 14 days.


Do you have a fever or above normal temperature?


Have you experienced shortness of breath or had trouble breathing?


Do you have a dry cough?


Do you have a runny nose?


Have you recently lost or had a reduction in your sense of smell?


Do you have a sore throat?


Have you been in contact with someone who has tested positive for
COVID‐19?


Have you tested positive for COVID‐19?


Have you been tested for COVID‐19 and are awaiting results?


Have you traveled outside the United States by air or cruise ship in
the past 14 days?


Have you traveled within the United States by air, bus or train within
the past 14 days?

 INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the risks of contracting COVID-19 from the dental office and dental procedures. I reaffirm that I am not a carrier of COVID-19 nor infected with COVID-19 to the best of my knowledge. I do voluntarily assume any and all reasonable medical/dental risks, including risk of harm, if any, which may be associated with any phase of my treatment as a result of the COVID-19 pandemic. I acknowledge that the nature and purpose of the dental procedures recommended under the current circumstances and restrictions have been explained to me and I have been given the opportunity to ask questions.


By signing this document, I acknowledge that the answers I have provided above are true and accurate.

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