Even after following protocols set by the American Dental Association and our state’s dental association, it is still possible to contract COVID-19 while at a dental office. We are following all guidelines to minimize the risk of transmission.
 

• I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic. I understand that the COVID-19 virus has a long incubation period during which carriers of this virus may not show symptoms and may still be highly contagious.     Initial Here *      
• I understand that – due to the frequency of visits of other dental patients, the characteristics of the COVID-19 virus, and the characteristics of dental procedures – I have an elevated risk of contracting the COVID-19 virus simply by being in a dental office.    Initial Here *    
• I confirm that I am not presenting any of these COVID-19 symptoms:    Initial Here *    
  • Fever
  • Shortness of breath
  • Dry cough
  • Runny nose
  • Sore throat
• I confirm that I have not been in contact with a person who has been diagnosed with COVID19 within the past 14 days.    Initial Here *    
• 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 six feet for a period of 14 days to anyone who has recently traveled, and this is not possible with dentistry.    Initial Here *    
• I verify that I have not traveled outside the United States in the past 14 days.    Initial Here *    
• I verify that I have not traveled domestically within the United States by commercial airline, bus or train within the past 14 days.    Initial Here *