COVID-19 Pandemic Emergency Dental Treatment Consent Form I, ________________________ , knowingly and willingly consent to have emergency dental treatment completed during the COVID-19 pandemic. (TYPE FULL NAME)* First Last 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. It is impossible to determine who has it and who does not given the current limits in virus testing. Dental procedures create water spray. The ultra-fine nature of the spray can linger in the air for minutes to sometimes 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 may have an elevated risk of contracting the virus simply by being in a dental office. _____ (INITIAL HERE)*I have been made award of the CDC, ODA, and ADA guidelines that under the current pandemic all non-urgent 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 within the next 3-6 months. _____ (INITIAL HERE)*I confirm I am seeking treatment for a condition that meets these criteria. ____ (INITIAL HERE)*Read the statement below and initial here.*I confirm that I am not presenting any of the following symptoms of COVID-19 listed below: Fever Shortness of Breath Dry Cough RunnyNose Sore Throat Loss of Smell Loss of Taste I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. I also understand that the CDC recommends social distancing of at least 6 feet for a period of 14 days to anyone who has traveled recently, and this is not possible with dentistry. _____ (INITIAL HERE)*I verify that I have not traveled outside the United States in the past 14 days to countries that have been affected by COVID-19. _____ (INITIAL HERE)*I verify that I have not traveled domestically within the United States by commercial airline, bus, or train within the past 14 days. _____ (INITIAL HERE)*Name* First Last Date* Date Format: MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
