Downlaod COVID-19 Pandemic Emergency Dental Treatment Consent Form

COVID-19 Pandemic Emergency Dental Treatment Consent Form
I, ________________________________, knowingly and willingly consent to having
emergency 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. Given the current limits in virus testing,
it is impossible to determine who has it and who does not have COVID-19.
Dental procedures create water spray (aerosols), which is one way the disease can be spread.
The ultra-fine nature of the spray can linger in the air for several minutes to hours, which can
transmit the COVID-19 virus.
● I understand that due to the frequency of visits of other dental patients, the
characteristics of the virus, and the characteristics of dental procedures, that I have an
elevated risk of contracting the virus simply by being in a dental office. ________ (Initial)
● I have been made aware of the Centers for Disease Control and Prevention (CDC) and
American Dental Association (ADA) guidelines that under the current pandemic all nonurgent
dental care is not recommended. Dental visits should be limited to the treatment
of pain, infection, conditions that significantly inhibit normal operation of teeth and
mouth, and issues that may cause anything listed above during the next 3-6 months.
________ (Initial)
● I confirm I am seeking treatment for a condition that meets these criteria. ________
(Initial)
I confirm that I am not presenting any of the following symptoms of COVID-19 listed below:
● Fever
● Shortness of breath
● Dry cough
● Runny nose
● Sore throat
________ (Initial)
I understand that air travel significantly increases the risk of contracting and transmitting the
COVID-19 virus. The CDC recommends social distancing of at least 6 feet for a period of 14
days around anyone who has traveled by air, and this distance is not possible with dentistry.
________ (Initial)
● I verify that I have not traveled outside the United States during the past 14 days to
countries that have been affected by COVID-19. ________ (Initial)
● I verify that I have not traveled within the United States by commercial airline, bus, or
train within the past 14 days. ________ (Initial)
Name ____________________________________ Date ____________________