CORONAVIRUS PATIENT CONSENT FORM

Our Governor allowed dental offices to re-open for elective treatment with certain safeguards. All patients, dentists and staff (both front and back) will be screened for COVID-19 daily.

The Center of Disease Control identified nine symptoms associated with Coronavirus.

My Temperature at ___ : ___ am/pm is ____ºF.  [The dental office will fill in this line.]  You will be asked to leave if your temperature meets or exceeds 100.4 ºF. The CDC considers such a reading to indicate a fever.

Please complete all questions below. In the past 24 hours:

• Cough    

  Yes

  No

• Muscle pain    

  Yes

  No

• Headache    

  Yes

  No

• Sore throat    

  Yes

  No

• Shortness of breath or difficulty breathing    

  Yes

  No

• Chills    

  Yes

  No

• Repeated shaking with chills    

  Yes

  No

• New loss of taste or smell    

  Yes

  No

As of this morning, none of our doctors or staff exhibit any Coronavirus symptoms (using the same screening as above); however, we have NOT BEEN MEDICALLY TESTED for COVID-19 and cannot guarantee that either we or our other patients are Coronavirus-free.

For your safety, our office has increased hygiene measures since the outbreak.

Given this knowledge, and knowing that I possibly could contract COVID-19 at this office (through the doctors, staff, or from other patients, and despite the office’s best intentions), I nevertheless voluntarily wish to continue with my elective dental treatment and hold the doctor and staff harmless should I come down with Coronavirus.

I have read this page and the content in full and have no questions.

Date

• Name    
• Phone    
• Email Address    

• Patient Signature    
• _______________________________________
  Temperature taken by (signature)

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