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COVID‐19 PANDEMIC ‐ PATIENT CONSENT

DENTAL PROFESSIONALS PATIENT ACKNOWLEDGEMENT

Receiving Dental Treatment During the COVID-19 Pandemic

Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19 at any time or in any place. While our office complies with the State Health Department and the Centers for Disease Control and Prevention Infection Control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees. Since we are a place of public accommodation, other persons (including other patients and/or employees) could be infected, with or without their knowledge. Despite Dental Professional’s careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office. “Social Distancing” nationwide has reduced the transmission of the Coronavirus. Although we have taken measures to provide social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, dentist, dental staff, and sometimes other patients at all times.

In order to reduce the risk of spreading COVID-19, Dental Professionals will take your temperature upon entering the office/prior to treatment, and will review a number of “screening” questions for you. For the safety of our staff, other patients, and yourself, we appreciate your truthful answers at each appointment.

Patient Date Of Birth

Date

I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and communicable diseases and despite if I have a compromised immune system, I consent to dental treatment and the risks of complications with such diseases in a dental office setting.

By signing this document, I acknowledge that the answers I provide during my pre-appointment screenings will be true and accurate. I also agree to inform Dental Professionals prior to my appointments if anyone in my household is experiencing Covid-19 or if I, or anyone in my household is experiencing any of the symptoms of Covid-19 including, but not limited to: fever, cough, shortness of breath, recent loss of taste or smell, or anyother flu-like symptoms. I also agree to inform Dental Professionals prior to my appointment if I, or anyone in my household, is under quarantine for exposure to Covid-19, so I can be rescheduled accordingly.

Patient First Name

Patient Last Name

Signature (Guardian if under 18)