COVID-19 Pandemic

• I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic. I understand that the COVID-19 virus has a long incubation period during which carriers of this virus may not show symptoms and may still be highly contagious.
• I understand that – due to the frequency of visits of other dental patients, the characteristics of the COVID-19 virus, and the characteristics of dental procedures – I have an elevated risk of contracting the COVID-19 virus simply by being in a dental office.
• I confirm that I am not presenting any of these COVID-19 symptoms:

Fever • Shortness of Breath • Dry cough • Runny nose • Sore throat

I confirm that I have not been in contact with a person who has been diagnosed with COVID-19 within the past 14 days.

I understand that air travel significantly increases my risk of contracting and transmitting the
COVID-19 virus, and the CDC recommends social distancing of at least six feet for a period of 14 days to anyone who has recently traveled, and this is not possible with dentistry.

I verify that I have not traveled outside the United States in the past 14 days.

I verify that I have not traveled domestically within the United States by commercial airline, bus or train within the past 14 days.

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.