Consent Form

COVID-19 Pandemic Emergency Dental Treatment Consent Form

I, (Parent/Guardian), knowingly and willingly give consent to have treatment completed for my child 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 water spray. 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 patients, the characteristics of the virus, and the characteristics of dental procedures, that I may have an elevated risk of contracting the virus simply by being in a dental office. (Initial).

I confirm that my child is not presenting any of the following symptoms of COVID-19 listed below:

  • Fever
  • Shortness of breath
  • Dry Cough
  • Runny nose
  • Sore throat
  • Loss of smell
  • Loss of taste