Covid-19 Pandemic – Dental Treatment – Patient Consent Form

Risk factors for acute respiratory illness, including COVID-19, include fever, cough, and difficulty Breathings as well as recent travel to an impacted area, close contact with a confirmed or probable case of COVID-19, and/or close contact with a person who has recently travelled to an impacted area.

The best available scientific evidence is that the virus which causes covid-19 is transmitted through the release of droplets into the air onto surfaces, including by sneezing or coughing. Certain dental procedures create water spray which may contribute to how the virus is spread. The ultra-fine nature of the spray can linger in the air, which may increase risk of transmission of the COVID-19 virus.

The COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. Without testing, it is impossible to determine who has it and who does not. I understand that while social distancing of at least 2 metres is recommended, it is not possible to maintain this distance and receive dental treatment. Due to the frequency of visits of other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there may be an elevated risk of contracting the virus in a dental office.

Acknowledgement and Consent

  • I have received information about COVID-19 and its symptoms and risk factors. I acknowledge that I have informed the dental practice if I have ANY of these symptoms or risk factors.

  • I understand and accept the risks of transmission of the virus in a dental office setting.

  • I have had the above treatment explained to me, including the risks and benefits, treatment alternatives, cost, follow-up requirements, and consequences of no treatment.

  • I have had an opportunity to ask questions and have had my questions answered to my satisfaction.

  • I consent to and wish to proceed with above dental treatment.

Printed Name :


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