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(COVID-19) Pandemic Dental Treatment Consent Form
CLICK Here to Read about CDC Coronavirus (COVID-19) Info
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Purpose of Consent
Dear Parents/Patient,
You have come to our office today for a routine dental evaluation and/or treatment that will be done during the COVID-19 pandemic. Please be advised of the following:
While our office complies with State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees.
Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients)could be infected, with or without their knowledge. In order to reduce the risk of spreading COVID-19, we have asked you a number of “screening” questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.
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 or my child has an elevated risk of contracting the virus simply by being in a dental office.
I verify that my child does not have
heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders
and therefore does not have an increased risk of COVID19 related complications.
I understand that air travel significantly increases our risk of contracting and transmitting the COVID-19 virus. Because the CDC recommends social distancing of at least 6 feet for a period of 14 days to anyone who has, please note that this is not possible with dentistry.
I confirm that I or my child are not presenting any of the following symptoms of COVID-19 that includes
Fever, Shortness of Breath, Dry Cough, Runny Nose, or a Sore Throat.
I confirm that I or my child has not lost sense of taste and/or smell
I verify that neither I nor my child has traveled outside of the United States in the past 14 days to countries that have been affected by COVID-19.
I verify that neither I nor my child have traveled domestically within the United States by commercial airline, bus, or train within the past 14 days.
If I cannot truthfully sign any of the above statements, the dentist has strongly encouraged me to contact my primary physician or public health department to determine if I should be seen or tested before coming in for any dental care.
This dental provider reserves the right to contact their local and state health department authorities to report any patient suspected of having COVID-19.
I give Smiles for Kids Pediatric Dentistry permission to treat my child. This may involve examination, x-ray, and/or other tests. The treatment may necessitate the usage of high-speed drills that produce aerosol. I understand that I will be in close proximity to the doctor and other team members.
Purpose of Consent:
By signing this form, you are knowingly and willingly consenting to have dental treatment for your child completed during the COVID-19 pandemic. 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 a 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. We encourage you to read it carefully and completely before signing this Consent.
Child's Name
Your Name:
Relationship to Patient:
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Father
Mother
Guardian
Date
Signature