knowlingly and willingly consent to have emergency dental treatment 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 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 patients, the characteristics of the virus, and the characteristics of dental procedures, that I have elevated the risk of contracting the virus simply by being in the dental office.

I have been made aware of the CDC, PDA and ADA guidelines that under the current pandemic all non-urgent dental care is not recommended.  Dental visits should be limited to the treatment of pain, infection, conditions that significantly inhibit normal operation of teeth and mouth, and issues that may cause anything listed above in the next 3-6 months.

I confirm that I am seeking treatment for a condition that meets these criteria.

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

Fever, Shortness of breath, Dry caugh, Runny nose, Sore throat

I understand that air travel significantly increases my risk of contracting and transmitting COVID-19 virus.  And 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 traveled outside the United States in the past 14 days to countries that have been affected by the COVID-19 virus.

I verify that I have not traveled domestically within the United States by commercial airline, bus or train within the past 14 days.

Our goal is to provide a safe environment for our patients and staff, and to advance the safety of our local community.  This document provides information we ask you to acknowledge and understand regarding the COVID-19 virus.

The COVID-19 virus is a serious and highly contagious disease.  The World Health Organization has classified it as a pandemic.  You could contract COVID-19 from a variety of sources.  Our practice wants to ensure you are aware of the additional risks of contracting COVID-19 associated with dental care.

The COVID-19 virus has a long incubation period.  You or your healthcare providers may have the virus and not show symptoms and yet still be highly contagious.  Determining who is infected by COVID-19 is challenging and complicated due to limited availability for virus testing.

Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office.

Dental procedures create water spray which is one way the disease is spread.  The ultra-fine nature of the water spray can linger in the air for a long time, allowing for transmission of the COVID-19 virus to those nearby.

You cannot wear a protective mask over your mouth to prevent infection during treatment as your healthcare providers need access to your mouth to render care.  This leaves you vulnerable to COVID-19 transmission while receiving dental treatment.

Pursuant to statements from the Center for Disease Control (CDC) and the American Dental Association (ADA), non-essential or elective treatment, based on the assessment of our staff, will be rescheduled.  According to the ADA, dental emergencies are "potentially life threatening and require immediate treatment to stop ongoing tissue bleeding (or to) alleviate severe pain or infection."  The ADA also recommends that urgent dental care which "focuses on the management of conditions that require immediate attention to relieve severe pain and/or risk of infection and to alleviate the burden on hospital emergency departments" be provided in as minimally invasive a manner as possible.

I confirm that I have read the Notice above and understand and accept that there is an increased risk of contracting the COVID-19 virus in the dental office or with dental treatment.  I further confirm I am seeing treatment for a  condition that meets the emergent or urgent criteria noted above.  I understand and accept the additional risk of contracting COVID-19 from contact at this office.  I also acknowledge that I could contract the COVID-19 virus from outside this office and unrelated to my visit here.