COVID-19 Emergency Consent for Treatment

I, Your Name (patient or guardian) knowingly and willingly consent to have emergency dental treatment for during the COVID-19 pandemic.

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms, and still be highly contagious. It is impossible to determine who has it and who does not, given the current limits in virus testing.

Dental procedures create water spray (aerosols) which is how the disease is spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the COVID-19 virus.

• I understand that due to the frequency of visits of other patients, the characteristics of the virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the virus simply by being in a dental office. (Initial)
• I have been made aware of the NY state of emergency, CDS, and ADA guidelines that under the current pandemic all non-urgent dental care is not recommended. Dental visits should be limited to the treatment of pain, infection, conditions that significantly inhibit normal function of teeth and mouth, and issues that may cause anything listed above within the next 3-6 months. I confirm I am seeking treatment for a condition that meets these criteria. (Initial)

I consent to having my temperature taken, and confirm that I am not presenting any of the following symptoms of COVID-19 listed below: (Initial)

• Fever
• Shortness of breath
• Dry cough
• Runny nose
• Sore throat

As a precondition to rendering treatment, I have not within the past 14 days travelled in a commercial airline, been in close proximity (less than 6 feet proximity) at a gathering of 10 or more persons, or have had close contact with a person who has confirmed positive or suspected to be positive for COVID-19.

I consent to the proposed treatment by my dentist