Consenting For Treatment During The COVID-19 Pandemic
I acknowledge and understand that there is an increased risk that COVID-19 can be transmitted in any place of public accommodation, including a dental office, and I have been informed that my dentist desires to protect the safety of the dental office and the patients, staff and other individuals who come upon the premises.
Accordingly, as a precondition to rendering treatment, I understand that I will need to complete a questionnaire to screen for symptoms commonly associated with COVID-19, including fever, shortness of breath, dry cough, running nose or sore throat and that I have not, within the past 14 days, travelled by airplane, been in close proximity (less than 6 feet proximity) at a gathering of 10 or more persons, or had close contact with a person who has confirmed positive or suspected to be positive for COVID-19.
YOU WILL NEED TO COMPLETE THIS CONSENT AGAIN, IN WRITING BEFORE YOUR APPOINTMENT
Accordingly, as a precondition to rendering treatment, I understand that I will need to complete a questionnaire to screen for symptoms commonly associated with COVID-19, including fever, shortness of breath, dry cough, running nose or sore throat and that I have not, within the past 14 days, travelled by airplane, been in close proximity (less than 6 feet proximity) at a gathering of 10 or more persons, or had close contact with a person who has confirmed positive or suspected to be positive for COVID-19.
YOU WILL NEED TO COMPLETE THIS CONSENT AGAIN, IN WRITING BEFORE YOUR APPOINTMENT
