www.aquadentalaustin.com - Dental Patient Consent Form

Dental Patient Consent Form
The patient , will hold harmless and indemnify the doctor, practice, associates, employees, successors, assigns, legal representatives, organizers, sponsors, and supervisors, against any claims, and actions, in exchange for dental treatment during the events of COVID-19 National Emergency.
"You are receiving dental care during the events of a COVID-19 National Emergency. Please be advised that there may be risks in being in the proximity of dentists, patients, and staff. We are taking precautions to limit the spread of disease, yet there is still a possibility of transmission."
Acknowledgement
I , make this decision of my own free will, relying upon my knowledge and judgment of any injury I may have sustained or possible transmission of COVID-19 during treatment, and my decision to release has not been affected by any false statements or representations pertaining to those injuries. I understand that this action is just a business decision and agree this represents a compromise between the patient and the doctor. Accordingly, this agreement is not an admission of any liability regarding the doctor, practice, associates, employees, successors, assigns, legal representatives, organizers, sponsors, and supervisors, against any claims and actions. I have carefully read this release and understand its contents, and I am signing it of my own free act.
Patient / Guardian Signature*

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Patient / Guardian Name*

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Date*

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Dental Patient Consent Form

Acknowledgement