COVID-19 Emergency Treatment Consent
Due to the desire to halt the spread of the COVID-19 virus, it has been ordered and directed that there be a temporary suspension of all elective procedures that can be delayed without undue risk to the patient as determined by your treating dentist.
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 their desire to protect their patients, staff and the community at large.
As a prerequisite to obtaining the emergency 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 30 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.
I hereby consent to the treatment proposed by my dentist.