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Patient Treatment Consent Form

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

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 *
 
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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 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.

 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
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