halum covid 19 form

COVID-19 Precautions: Patient Treatment Consent Form( * mandatory to fill )

Patient First Name *

Patient Last Name *

Patient Date of Birth *

I consent for my child to receive treatment from Dentistry for Children during the COVID-19 outbreak.

I understand there is much to learn about the newly emerged COVID-19 including how it spreads and transmitted.

I understand that based on what is currently known about COVID-19 the spread is thought to occur mostly from person-to-person via respiratory droplets among close contacts. I understand that close contact can occur from being within approximately 6 feet of someone with COVID-19 for a prolonged period of time or by having direct contact with infectious secretions from someone with COVID-19.

I understand that carriers of COVID-19 may not show symptoms but may still be highly contagious.

I understand that due to the unknowns of this virus, the number of other patients that have been in the practice and the nature of the procedures performed here, that I have an increased risk of contracting the virus by being in the practice and by receiving treatment in the practice.

I confirm I am seeking dental treatment regardless of any potential risks involved. *

I understand that dental procedures have the potential to include aerosol-generating procedures as well as anticipated splashes and sprays, which are some of the ways that COVID-19 can be spread.

I understand that the symptoms listed below are representative of COVID-19:

Fever
Dry Cough
Shortness of Breath
Temperature
Persistent pain or pressure in the chest
Bluish lips or face

I confirm that I nor my child/children do not display or currently have any of the symptoms that are representative of COVID19, which are outlined above: *

I understand that all travelers arriving from a country or region with widespread ongoing transmission, as outlined by the CDC, should stay home for 14 days to practice social distancing and monitor their health after their arrival.

I confirm that I have not traveled to any of the countries or regions with widespread ongoing transmission (Level 3 Travel Health Notice) in the past 14 days. *

I confirm, to the best of my knowledge, that I have not had close contact with an individual diagnosed with COVID-19 in the past 14 days. *

I confirm I will allow Dentistry for Children’s staff to check mine (parent) and my child(ren)’s temperature upon arrival using a non-contact thermometer unit. *

Parent, Guardian Signature *

(Please click below to draw/upload sign)

(Your IP Address : )

COVID-19 Precautions: Patient Treatment Consent Form

First Name: Last Name: Date Of Birth:

I consent for my child to receive treatment from Dentistry for Children during the COVID-19 outbreak.

I understand there is much to learn about the newly emerged COVID-19 including how it spreads and transmitted.

I understand that carriers of COVID-19 may not show symptoms but may still be highly contagious.

I confirm I am seeking dental treatment regardless of any potential risks involved.

I understand that dental procedures have the potential to include aerosol-generating procedures as well as anticipated splashes and sprays, which are some of the ways that COVID-19 can be spread.

I understand that the symptoms listed below are representative of COVID-19:

Fever
Dry Cough
Shortness of Breath
Temperature
Persistent pain or pressure in the chest
Bluish lips or face

I confirm that I nor my child/children do not display or currently have any of the symptoms that are representative of COVID19, which are outlined above:

I confirm that I have not traveled to any of the countries or regions with widespread ongoing transmission (Level 3 Travel Health Notice) in the past 14 days.

I confirm, to the best of my knowledge, that I have not had close contact with an individual diagnosed with COVID-19 in the past 14 days.

I confirm I will allow Dentistry for Children’s staff to check mine (parent) and my child(ren)’s temperature upon arrival using a non-contact thermometer unit.


PATIENT OR PARENT/GUARDIAN SIGNATURE		DATE & IP ADDRESS