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    COVID-19 Pandemic Emergency Dental Treatment Consent Form

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    PRABHUDEVA
    This document is a COVID-19 emergency dental treatment consent form. It acknowledges that dental procedures produce spray that can transmit the virus, whose carriers may be asymptomatic. It confirms the patient needs urgent care as defined by CDC guidelines, isn't showing COVID-19 symptoms, and hasn't recently traveled domestically or internationally. The patient consents to treatment while recognizing risks of virus transmission given limits to testing and distancing in a dental setting during the pandemic.

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    COVID-19 Pandemic Emergency Dental Treatment Consent Form

    Uploaded by

    PRABHUDEVA
    21 views1 page
    This document is a COVID-19 emergency dental treatment consent form. It acknowledges that dental procedures produce spray that can transmit the virus, whose carriers may be asymptomatic. It confirms the patient needs urgent care as defined by CDC guidelines, isn't showing COVID-19 symptoms, and hasn't recently traveled domestically or internationally. The patient consents to treatment while recognizing risks of virus transmission given limits to testing and distancing in a dental setting during the pandemic.

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    COVID.docx

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    This document is a COVID-19 emergency dental treatment consent form. It acknowledges that dental procedures produce spray that can transmit the virus, whose carriers may be asymptomatic. It confirms the patient needs urgent care as defined by CDC guidelines, isn't showing COVID-19 symptoms, and hasn't recently traveled domestically or internationally. The patient consents to treatment while recognizing risks of virus transmission given limits to testing and distancing in a dental setting during the pandemic.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    21 views1 page

    COVID-19 Pandemic Emergency Dental Treatment Consent Form

    Uploaded by

    PRABHUDEVA
    This document is a COVID-19 emergency dental treatment consent form. It acknowledges that dental procedures produce spray that can transmit the virus, whose carriers may be asymptomatic. It confirms the patient needs urgent care as defined by CDC guidelines, isn't showing COVID-19 symptoms, and hasn't recently traveled domestically or internationally. The patient consents to treatment while recognizing risks of virus transmission given limits to testing and distancing in a dental setting during the pandemic.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    COVID-19 Pandemic Emergency Dental Treatment Consent Form

    I, _______________________________________, knowingly and willingly consent to have


    emergency dental treatment completed during the COVID-19 pandemic.
    I understand the COVID-19 virus has a long incubation period during which carriers of the
    virus may not show symptoms and still be highly contagious. It is impossible to determine
    who has it and who does not given the current limits in virus testing.
    Dental procedures create water spray. It is unclear as to how long the ultra-fine nature of
    the spray may linger in the air, which can transmit the COVID-19 virus.
     I have been made aware of the CDC and ADA guidelines that under the current
    pandemic all non-urgent dental care is not recommended. Dental visits should be
    limited to the treatment of pain, infection, conditions that significantly inhibit
    normal operation of teeth and mouth, and issues that may cause anything listed
    above within the next 3-6 months. ___________ (Initial)
     I confirm I am seeking treatment for a condition that meets these criteria.
    ___________ (Initial)

    I confirm that I am not presenting any of the following symptoms of COVOID-19 listed
    below:
     Fever
     Shortness of Breath
     Loss of Sense of Taste or Smell
     Dry Cough
     Runny Nose
     Sore Throat
     ___________ (Initial)

    I understand that air travel significantly increases my risk of contracting and transmitting the
    COVID-19 virus. And the CDC recommends social distancing of at least 6 feet for a period of
    14 days to anyone who has, and this is not possible with dentistry. ___________ (Initial)
     I verify that I have not travelled outside the India in the past 14 days to countries
    that have been affected by COVID-19. ___________ (Initial)
     I verify that I have not travelled domestically within the India by commercial airline,
    bus, or train within the past 14 days. __________(Initial)

    Name____________________________________ Date____________________

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