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, you have been exposed to Covid-19, or you have travelled outside of the US or domestically by airline, bus or train in the past 14 days.
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-10 listed below:
- Shortness of Breath
- Dry Cough
- Runny Nose
- Sore Throat
I understand that air travel significantly may increase my 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 to anyone who has, and this is not possible with dentistry.
- I verify that I have not travelled outside of the Unites States in the past 14 days to countries that have been affected by COVID-19.
- I verify that I have not travelled domestically within the United States by commercial airline, bus or train within the past 14 days.
- I verify that I have not come in direct contact with anyone who has tested positive in the last 14 days.
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.
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.