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COVID-19 Pandemic Dental Treatment Consent Form

If you have previously completed this form, no need to resubmit. Please contact us if you are experiencing any  of the symptoms below or if you have been exposed to Covid-19.

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. Social distancing nationwide has reduced the transmission of the Coronavirus.  Although Lund Orthodontics have taken measures to provide social distancing, due to the nature of the  procedures provided, it is not possible to maintain social distancing between the patient, doctor, clinicians and  other patients at all times. 

Dental procedures create water spray which is how the disease is spread. 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 patents, 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. 

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 

Although exposure is unlikely, do you accept the risk and consent to dental treatment for yourself or your minor  child? I understand that if the answer to any of the health screening questions is yes, I will be asked to  reschedule today’s appointment.

  • MM slash DD slash YYYY

Thank you for your continued trust in our practice. As with the transmission of any communicable disease like  a cold or the flu, you may be exposed to COVID-19 at any time or in any place. Be assured that we have  always followed state and federal regulations and recommended universal personal protection and disinfection  protocols to limit transmission of all diseases in our office and continue to do so.

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