I affirm that DBM Dental, Ltd, Dr. Michael Perry and team members operating within this practice have offered me the opportunity to reschedule my dental treatment to an alternative date. I also affirm that I have freely elected to proceed with my essential or non-essential dental procedure at this time.
I have been made aware by the Practice that while the Practice has implemented several new safety measures to prevent or reduce the spread of the COVID-19 virus, they cannot make any guarantees. The staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since they are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge. Therefore, I fully understand that proceeding with the treatment today could potentially have exposure-risk associated with COVID-19.
I understand that acquiring COVID-19 can lead to severe symptoms such as fever, chest pain, shortness of breath and respiratory complications and other associated symptoms. Advanced COVID-19 disease can also lead to prolonged hospitalization, intensive care admission, mechanical ventilation, or even possible death.
I also agree that neither I nor my family members/individuals with whom I currently reside with have been exposed to or are experiencing any of the following symptoms in the past 14-21 days.
- Shortness of breath
- Chest pain
- Runny nose, loss of smell or taste
- Sore throat
- Fatigue and body aches
- Other symptoms associated with COVID-19
- Confirmed or suspected COVID-19 (Coronavirus) Infection
I am consenting to this procedure with full understanding and disclosure of such risks and alternatives. I am consenting to a charge per visit of $10.00 for the office sterilization fee with these new procedures until further notice.
If the patient is under 18, a parent or guardian must sign below to consent to the procedure with full understanding and disclosure of such risks and alternatives.
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.