Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Are you in the at high risk category? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Consent (Not High Risk) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

Consent for at High Risk Category Patients

People who acquire the sickness, covid 19, show an array of symptoms. Some people are termed at high risk category because if they develop covid 19 they have worse symptoms and have a higher chance to not recover. High risk category factors are pregnancy, diabetes, cardiovascular disease, hypertension, lung diseases including moderate to severe asthma, active malignancy, immunocompromised, or are over age 70. We must weigh the pros and cons of having dental treatment.

Even though the risk of being in contact with the corona virus at the dental office is extremely low we do offer high risk patient some options:

1)    Defer treatment until the pandemic is over or a vaccine is developed

2)    Schedule patient for early morning or after lunch when our office is less busy and there the possibility of less aerosol producing procedures

3)    Modify dental treatment to limit clinic exposure 

Please ask us if you have any questions or concerns or if you want us to expand on anything listed above. If you feel comfortable to proceed please complete the next paragraph.

I understand the I fall into an at high risk category of: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
DentistDiscussion {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Consent (High Risk) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
I have agreed to proceed with the following dental treatment(s) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Click here to read about our PPE and new procedures during the COVID-19 pandemic.

I verify the information I have provided on this form is truthful and accurate. I consent to have dental treatment completed during the COVID-19 pandemic.

{ binding firstError.message }
{ binding firstError.message }
Patient Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Are you in the at high risk category? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Consent (Not High Risk) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

Consent for at High Risk Category Patients

People who acquire the sickness, covid 19, show an array of symptoms. Some people are termed at high risk category because if they develop covid 19 they have worse symptoms and have a higher chance to not recover. High risk category factors are pregnancy, diabetes, cardiovascular disease, hypertension, lung diseases including moderate to severe asthma, active malignancy, immunocompromised, or are over age 70. We must weigh the pros and cons of having dental treatment.

Even though the risk of being in contact with the corona virus at the dental office is extremely low we do offer high risk patient some options:

1)    Defer treatment until the pandemic is over or a vaccine is developed

2)    Schedule patient for early morning or after lunch when our office is less busy and there the possibility of less aerosol producing procedures

3)    Modify dental treatment to limit clinic exposure 

Please ask us if you have any questions or concerns or if you want us to expand on anything listed above. If you feel comfortable to proceed please complete the next paragraph.

I understand the I fall into an at high risk category of: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
DentistDiscussion {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Consent (High Risk) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
I have agreed to proceed with the following dental treatment(s) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Click here to read about our PPE and new procedures during the COVID-19 pandemic.

I verify the information I have provided on this form is truthful and accurate. I consent to have dental treatment completed during the COVID-19 pandemic.

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }