Patient Consent Form
I understand the novel coronavirus causes the disease known as COVID-19. Symptoms may include (but are not limited to): fever, cough, sore throat, shortness of breath, difficulty breathing, flu-like symptoms, runny nose, loss of taste/smell, chills, fatigue, rash.
I have considered whether I am in a high-risk category, including (but not limited to): diabetes, cardiovascular disease, hypertension, lung diseases including moderate to severe asthma, being immunocompromised, active cancer, over age 65.
I understand that due to the characteristics of the COVID-19 and the limitations on physical distancing when out in public and during dental procedures, that there is a risk of contracting COVID-19, especially where local prevalence rates are high.
I understand that the dental practice is following all infection prevention and control guidelines in order to minimize the risk to patients, the dental team, and the community.
I understand that there may be modifications to appointment scheduling, available treatment options, and office protocols during the pandemic to help eliminate the spread of the virus.