Name: COVID-19 Consent Form - Greenberg Oral Surgery
Published: 2020-05-26T14:26:03+00:00

COVID-19 Pandemic 

Dental Treatment Consent Form

Subsequent to following protocols set by the American Dental Association and our state’s dental association, it is still possible to contract COVID-19 while at a dental office. We are following all guidelines to minimize the risk of transmission.
I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.
I understand that the COVID-19 virus has a long incubation period during which carriers of this virus may not show symptoms and may still be highly contagious.
I understand, due to the frequency of visits of other dental patients, the characteristics of the COVID-19 virus, and the characteristics of dental procedures I have an elevated risk of contracting the COVID-19 virus simply by being in a dental office.
o Fever o Shortness of breath o Dry cough o Runny nose o Sore throat
I confirm that I am not presenting any of these COVID-19 symptoms:
o Fever
o Shortness of breath
o Dry cough
o Runny nose
o Sore throat
Consent
I confirm that I have not been in contact with a person who has been diagnosed with COVID19 within the past 14 days.
Consent
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 six feet for a period of 14 days to anyone who has recently traveled, and this is not possible with dentistry.
Consent
I verify that I have not traveled outside the United States in the past 14 days.
Consent
I verify that I have not traveled domestically within the United States by commercial airline, bus or train within the past 14 days.
Printed name:*

(Patient)
Date of birth*
MM slash DD slash YYYY

(Patient)
Signature:*

(Patient or legal guardian)
Today’s date:*
MM slash DD slash YYYY
CAPTCHA

COVID-19 Consent Form

COVID-19 Pandemic

Dental Treatment Consent Form

Services

Quick Links

Visit Us

Social