COVID-19 Consent Form

Dental Treatment in the Era of Covid-19

Patient's First Name *

Middle Initial *

Patient's Last Name *

Thank you for your continued trust in our practice. As with the transmission of any
communicable disease like a cold or the flu, you may be exposed to Covid-19, also known as
“Coronavirus,” at any time or in any place. Be assured that we have always followed state and
federal regulations and recommended universal personal protection and disinfection protocols
to limit the transmission of all diseases in our office and continue to do so.

Despite our careful attention to sterilization, disinfection and use of personal barriers, there is
still a chance that you could be exposed to an illness in our office, just as you might be at your
gym, grocery store, or favorite restaurant. “Social Distancing” nationwide has reduced the
transmission of the Coronavirus. Although we have taken measures to provide social distancing
in our practice, due to the nature or the procedures we provide, it is not possible to maintain
the social distancing between the patient, dentist, hygienist, assistants, other staff and sometimes
other patients at all times.

Although exposure is unlikely, do you accept the risk and consent to treatment? *

Yes

No

Patient/Parent/Guardian Signature *

Clear

Today's Date *

Please Print Your Name *

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