COVID-19 Pandemic Dental Treatment Consent Form

Please correct the errors described below.

knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms but will still be highly contagious. It is not always possible to determine who has it and who does not given the current limits in virus testing.

I Understand

Yes No

Do you have or have you had any of the following symptoms of COVID-19 in the last 14 days

Fever or felt hot/feverish

Yes No

Shortness of Breath or Difficulty Breathing

Yes No

Cough

Yes No

Flu-like symptoms, gastrointestinal upset, headache or fatigue

Yes No

No Loss of taste and/or smell

Yes No

Do you have heart disease, diabetes, lung disease, kidney disease or any auto-immune disorder?

Yes No

Have you been exposed to anyone with a possible or confirmed case of COVID-19 in the last 14 days?

Yes No

Have you been tested for COVID-19?

Yes No

If yes ,Date

If yes, Results?

Have you been tested for COVID-19 antibodies?

Yes No

If yes ,Date

If yes, Result?

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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