I, ________________________________, knowingly and willingly consent to having dental treatment completed 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. Given the current limits in virus testing, it is impossible to determine who has it and who does not have COVID-19.
Dental procedures create water spray (aerosols), which is one way the disease can be spread. The ultra-fine nature of the spray can linger in the air for several minutes to hours, which can transmit the COVID-19 virus.
I confirm that I am not presenting any of the following symptoms of COVID-19 listed below:
I understand that air travel significantly increases the risk of contracting and transmitting the COVID-19 virus. The CDC recommends social distancing of at least 6 feet for a period of 14 days around anyone who has traveled by air, and this distance is not possible with dentistry.
I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence. It is my responsibility to inform this office of any changes in my personal or medical information. I authorize the dental team to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES
I, ___________________________________________, understand that Oasis Family Dental abides by the HIPAA Law and will protect the privacy of my personal information.