COVID-19 Pandemic

Dental Treatment Consent Form

Please correct the errors described below.

Even after following protocols set by the American Dental Association and our state’s dental association, it is still possible to contract COVID-19 while at a dental office. We are following all guidelines to minimize the risk of transmission.

  • 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.

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