Covid Treatment Consent Form in Lawrenceville, GA | Lawrenceville Pediatric Dentistry

I, _______________________________________, knowingly and willingly consent to have emergency 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. It is impossible to determine who has it and who does not given the current limits in virus testing.

Dental procedures create water spray. It is unclear as to how long the ultra-fine nature of the spray may linger in the air, which can transmit the COVID-19 virus.

Your Name*

I have been made aware of the CDC 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 operation of teeth and mouth, and issues that may cause anything listed above within the next 3-6 months.*

Your initials

I confirm I am seeking treatment for a condition that meets these criteria.*

Your initials

I confirm that I am not presenting any of the following symptoms of COVOID-19 listed below:

Fever
Shortness of Breath
Loss of Sense of Taste or Smell
Dry Cough
Runny Nose
Sore Throat

Your initials*

I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. And the CDC recommends social distancing of at least 6 feet for a period of 14 days to anyone who has, and this is not possible with dentistry.*

Your initials

I verify that I have not traveled outside the United States in the past 14 days to countries that have been affected by COVID-19.*

Your initials

I verify that I have not traveled domestically within the United States by commercial airline, bus, or train within the past 14 days.*

Your initials

Name*

First Last

Date*