Mandatory COVID-19 Screening and Consent Form

Your Name*

I, {yourName} , knowingly and willingly consent to have 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 an elevated risk of contracting the virus simply by being in dental office. *

(Initial)

I have been made aware of the CDC, ODA, and RCDSO guidelines that are under the current pandemic*

(Initial)

I confirm that I have not been in contact with a person that has been diagnosed with COVID-19 within the last 14 days. *

(Initial)

I understand that the CDC recommends social distancing of at least 6 feet to prevent transmission of disease and this is not possible with dentistry. *

(Initial)

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

(Initial)

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

(Initial)

Fever
Shortness of Breath
Dry Cough
Runny Nose
Sore Throat

I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. And the CDC recommends social distancing of at least 6 feet for period of 14 days to anyone who has, and this is not possible with dentistry. *

(Initial)

I verify that I have not traveled outside of the United States in the past 14 days to countries that have been affected by COVID-19. *

(Initial)

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

(Initial)

Signature*

Patients Name*

First NameLast Name

Date*

Date