At [INSERT PRACTICE NAME], we follow all requirements for Infection Control and Prevention, including all enhanced directives issued. We are taking all necessary precautions to prevent transmission of COVID-19, along with any and all other infection causing viruses or bacteria. Certain dental procedures create a water spray which is one way that the novel coronavirus can spread. Despite these efforts, given the unique attributes of the novel coronavirus, there may be an elevated risk of infection.
To help facilitate your appointment, please answer all fields below.
I hereby consent to dental treatment despite any possible elevated risks associated with such treatment during this time of the COVID-19 pandemic, which risks have been explained to me.
By submitting this example form, you agree to receive news, updates, and promotions from Hushmail. You can unsubscribe at any time.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.