Dental Treatment Consent

COVID-19 Pandemic

Please correct the errors described below.

Thank you for your continued trust in our practice.

Even after following protocols set by the American Dental Association, CDC and OSHA, it is still possible to contract COVID-19 while at a dental office. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as “coronavirus,” at any time or in any place. Be assured that we continue to follow state and federal regulations as well as recommended universal personal protective equipment (PPE) and disinfection protocols to limit transmission of all diseases in our office.

Despite our careful attention to sterilization, disinfection and the use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be exposed at your gym, grocery store or favorite restaurant. Nationwide social distancing has reduced the transmission of the coronavirus. Although we have taken measures to enable social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, dental healthcare team members and sometimes other patients at all times.

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.

COVID-19 Patient Screening Form

Add new row

Add new row

Add new row

Add new row

Add new row

Add new row

Add new row

Add new row

Add new row

Add new row

Add new row

Add new row

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.

Your information will be encrypted.

Loading...