COVID-19 Request for Treatment, Representations and Consent
Please correct the errors described below.
I hereby acknowledge and understand that there may be an increased risk that COVID-19 may be transmitted in any place of public accommodation, which includes my dentist’s office. I have been informed by my dentist of his/her desire to protect their patients, staff and the community at large. WE ARE TAKING EVERY PRECAUTION NECESSARY TO LIMIT THE EXPOSURE OF ANY VIRUS WITHIN OUR OFFICE.
I understand that despite my health care providers best efforts to identify potential carriers of the virus, we cannot guarantee that we are able to identify such individuals and prevent them from potentially bringing the virus to this office. Despite safeguards instituted to minimize infection, I understand that there is a risk that performing this procedure, and the care associated with it, may result in my becoming infected with the COVID-19 virus. Such infection could further result in significant sickness, disability, or death.
I understand that in addition to this Special Consent Form for An Elective Surgery or Procedure During the COVID-19 Pandemic, I will be provided a separate Consent Form for review regarding the particular surgery or procedure to be performed. I understand that this Special Consent Form is only being used because of the unique circumstances surrounding the pandemic.
As a prerequisite to obtaining the treatment proposed, I am confirming that I have none of the current commonly known symptoms of COVID-19 (fever, cough, shortness of breath, sore throat, loss of taste and/or smell sensation) and that I have not traveled by airplane, cruise ship, train or other form of public transportation. Further I have been practicing all current CDC guidelines with respect to “social distancing” and have NOT been in contact with a person who had a positive test for COVID-19 or suspected to be positive.
I hereby consent to the treatment proposed by my dentist.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.