COVID-19 Request for Treatment Representations and Consent

I hereby acknowledge and understand that there may be an increased risk that COVID-19 may be transmitted in any place of public accommodation, which includes my dentist’s office. I have been informed by my dentist of her desire to protect her patients, staff, and the community at large. We are taking every precaution necessary to limit the exposure of any virus within our office.

I understand that despite my health care providers’ best efforts to identify potential carriers of the virus, we cannot guarantee that we are able to identify such individuals and prevent them from potentially bringing the virus to this office.

As a prerequisite to obtaining the treatment proposed, I am confirming that I have none of the current commonly known symptoms of COVID-19 (fever, cough, shortness of breath, sore throat, loss of taste and/or smell sensation) and that I have not traveled by airplane, cruise ship, train or other form of public transportation in the past 14 days. Further, I have been practicing all current CDC guidelines with respect to “social distancing” and have NOT been in contact with a person who had a positive test for COVID-19 or suspected to be positive.

In accordance with American Dental Association recommendations, we will be adding a fee of $10 per visit for the additional PPE (personal protective equipment) cost required due to COVID-19 regulations.

I hereby consent to the treatment proposed by my dentist.

Patient Name:     Date:

Signature of Patient, Parent, or Guardian: