Consent to dental treatment during COVID-19

I am aware that the current COVID-19 pandemic brings a number of known and unknown risks. I have chosen to seek dental treatment during the pandemic in the knowledge that much is still unknown about the virus, its spread and the long term consequences of it.
I understand I will be around other people seeking dental treatment and I must take measures to keep socially distanced from others, wear a face covering, clean my hands when entering and leaving the practice. Due to the long incubation period of Coronavirus I must assume everyone is potentially infected and take careful personal measures.
I confirm that I understand the risks and benefits of the treatment proposed as explained to me by the dentist and that all my questions have been answered to my satisfaction.
I understand the practice must zone their appointments to comply with aerosol fallow time and as such certain appointments will be offered within a strict window of time. This ensures a safe envronment for the patients who will attend after me.
I understand that some procedures may not be available until the National alert level reduces to level 2. This includes scaling teeth with the ultrasonic scaler for routine check ups.
I agree to be treated at Deane Dental Practice for my dental needs.
I agree to inform the practice if I have any symptoms of Coronavirus and WILL NOT attend the practice. Instead I will seek to get a test and self isolate.

In consideration of my attendance at Deane Dental, I acknowledge and agree to the following: *

I may be an aymptomatic carrier as could any of the other patients that have attended before me, as such there is a small risk of transmission of COVID 19. I know this risk is reduced as the dental practice is following all cross infection procedures, social distancing measures and decontamination procedures I do not have any of the following symptoms: high temperature, a new, continuous cough, change or lost in sense of smell or taste or exhibiting any other symptoms relating to COVID-19 or any communicable disease within the last 14 days. I have not, nor any member(s) of my household, traveled by sea or by air, internationally to countries not in the travel corridors within the past 14 days. I have not been, nor any member(s) of my household, diagnosed to be infected of COVID-19 virus within the last 14 days. I am not waiting for a COVID 19 Result or test. I understand all above and agree to this.

By signing below I acknowledge that I have read this Consent form and understand its contents; that I have been sufficiently informed of the risks involved in attending and give my voluntary consent in signing it as my own free act and deed. I have had the chance to ask any questions and queries about my treatment at the practice

This Consent form will remain effective until laws and mandates relevant to COVID-19 are lifted. If I have any symptoms or anything that breaches this consent form, I must not enter the buliding and call the practice on 0161 478 2980 immediately to cancel this appointment.

I understand that I must give immediate notice to the practice of requiring to cancel an appointment. Any appointment that is NOT cancelled within 24 hours will be considered a failed appointment. I understand the practice reserve the right to deregister me if I fail my initial appointment/ two dental appointments within a year or if I cancel at short notice for 2 appointments.

Name *

First Name Last Name

Date of Birth *

Date

Date of Appointment *

Date

Signature

Clear

Date Signed *

Date