COVID-19 Patient Treatment Consent
I, _________________________________________, knowingly and willingly consent to have emergency dental treatment completed during the COVID-19 pandemic.
I understand the COVID-19 virus has a long incubation period during which carries of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has and who does not have the virus due to the current limits of testing.
Dental procedures create water spray, which is how the disease is spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the COVID-19 virus.
- I understand that due to the frequency of visits of other dental patients, the characteristics of the virus, and the characteristics of dental procedures, that I have evaluated the risks of contracting the virus simply by being in the dental office. _____________ (initial)
- I have been made aware of the CDC, ODA 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 function of teeth and mouth, and issues that may cause anything listed above within the next 3-6 months. _____________ (initial)
- I confirm that I am seeking treatment for a condition that meets these criteria. _____________ (initial)
I confirm that I am not presenting any of the following symptoms of COVID-19 listed below:
* Fever * Shortness of Breath
* Loss of Taste or Smell * Dry Cough
* Runny Nose * Sore Throat _____________ (initial)
I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. The CDC recommends social distancing of at least 6 feet for a period of 14-days.
- I verify that I have NOT traveled outside the United States in the last 21-days to counties that have been affected by COVID-19. _____________ (initial)
- I verify that I have NOT traveled domestically within the United States by commercial airline, train or car within the last 21-days. _____________ (initial)
Patient: ____________________________________________ DATE: ________________
Staff signature: ____________________________________ DATE: ________________