COVID-19 Consent Form COVID-19 PandemicDental Treatment Consent FormEven after 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 (INITIAL)*I understand that 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. (INITIAL)*I confirm that I am not presenting any of these COVID-19 symptoms (INITIAL)*- Fever - Shortness of breath - Dry cough - Runny nose - Sore throatI confirm that I have not been in contact with a person who has been diagnosed with COVID19 within the past 14 days (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 six feet for a period of 14 days to anyone who has recently traveled, and this is not possible with dentistry. (INITIAL)*I verify that I have not traveled outside the United States in the past 14 days. (INITIAL)*I verify that I have not traveled domestically within the United States by commercial airline, bus or train within the past 14 days. (INITIAL)*We ask that you please refrain from using your cell phone and having it out while in the officePatient Name (print)* First Last Signature*(Patient or legal guardian)Today's Date* Date Format: MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.