COVID-19 INFORMED CONSENT/ QUESTIONNAIRE

*Patient First Name & Last Name:

With community transmission of communicable diseases, you could be exposed anywhere to infectious disease including, but not limited to Covid-19 (also called Coronavirus). Our office is followed the State and Federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of communicable diseases. However, it is possible that these precautions will not always be successful in blocking the transmission of these diseases. Social distancing nationwide has reduced the transmission of COVID-19, However it is not possible to provide treatment with social distancing between the patient, staff and sometimes, other patients.

By presenting yourself for treatment, you assume and accept the risk that you may inadvertently be exposed to a communicable disease. If you have been exposed to a communicable disease prior to your dental appointment, you may spread the disease to the staff and to other patients in the practice.

1. I confirm that I do not have any of the following symptoms of COVID-19: Fever, shortness of breath, dry cough, runny nose, sore throat currently, or for the last 14 days.

2. I confirm that I have not tested positive/ been diagnosed with COVID-19 or been in contact with anyone who has within the last 14 days.

3. I agree then, if I were to exhibits any symptoms of, or am diagnosed with, COVID-19, I will immediately contact my dentist so that proper steps can be taken to limit the spread of this contagion.

Do you acknowledge and accept the risk of exposure in our office to a communicable disease, including but not limited to COVID-19, and consent to treatment?

Date:                                                                                               

Patient/ Guardian Signature: