This is not an appointment confirmation. We will contact you regarding your requested appointment date and time.
Please provide a legible, complete parent name signature on each signature line.
1. I hereby authorize doctor or designated staff to take x-ray, study models, photographs, and other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of dental needs for the patient named below.
2. Upon such diagnosis, I authorize doctor to perform all recommended treatment agreed upon by me and to employ such assistance as required to provide care.
3. I give consent to the doctor's or designated staffs use and disclosure of any oral, written or electric health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and dental care. I understand that only the minimum amount of information necessary to provide quality care will be used or disclosed and that a notice fully outlining the protection of my personal health information is available.
I acknowledge that I have read and understand these statements with my signature below.
1. I knowingly and willingly consent to dental treatment at Little Urban Smiles by any designated associates or employees during the reopening phase of COVID-19.
2. I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms yet are still highly contagious. It is impossible to determine who has COVID-19 and who does not given the current limitations and availability in COVID-19 viral testing.
3. Risk of transmission: I understand that due to the frequency of visits of other care dental patients, 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, even though standard precautions are being observed.
4. I am unaware of being a possible carrier or infected: I confirm that I have not tested positive for COVID19 in the last 30 days and that I am not presenting with any of the following:
5. Contact with infected: I confirm that I have not knowingly been in close contact (defined as 6 feet or less for a duration of fifteen minutes or more) with someone who has tested positive for COVID-19 in the last 14 days, or with anyone that has had the above stated symptoms in paragraph 4 (#4) in the last 14 days.
6. Public travel: I confirm that I have not traveled outside of the United States in the past 14 days. I confirm that I have not traveled domestically by commercial airline, bus, or train within the last 14 days.
7. If I receive an appointment time, and by or on the day of my appointment the answer to any of these above questions change or I experience any of the above mentioned symptoms, I will immediately alert office staff to reschedule an appointment at a suitable time.
I have been given the opportunity to ask any questions regarding the risks of contracting COVID-19 from the dental office and dental procedures. I reaffirm that I am not a carrier of COVID-19 nor infected with COVID-19 to the best of my knowledge. I voluntarily assume any and all medical/dental risks, including the substantial and significant risk of serious harm, if any, which may be associated with any phase of my treatment as a result of the COVID-19 pandemic. I acknowledge that the nature and purpose of the dental procedures recommended under the current circumstances and restrictions have been explained to me and that I have been given the opportunity to ask questions.