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 and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing.

Dental procedures create water spray. 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 frequenecy of visits of other dental patients, the characteristics of the virus, and the characteristics of dental procedures, that I may have an elevated risk of contracting the virus simply by being in a dental office.

I confirm that I am not presenting any of the following symptoms of COVID-19 listed below

  • Fever
  • Runny Nose
  • Shortness of Breath
  • Dry Cough
  • Sore Throat
  • Loss of Smell
  • Loss of Taste

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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