COVID -19 Patient Consent Form


Patient Consent for Treatment

Informed consent: Dental Treatment in the Era of COVID-19


Thank you for your continued trust in our practice.  As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as “coronavirus”, at any time or in any place.  Be assured that we continue to follow state and federal regulations as well as recommended universal personal protective equipment (PPE) and disinfection protocols to limit the transmission of all diseases in our office.


Despite our careful attention to sterilization, disinfection, and the use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be exposed at your gym, grocery store, or favorite restaurant.  Nationwide social distancing has reduced the transmission of the coronavirus.  Although we have taken measures to enable social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, dental healthcare team members, and sometimes other patients at all times.


INFORMED CONSENT: I have been given the opportunity to ask questions regarding the risks of contracting COVID-19 from the dental office and dental procedures.  I am unaware of being a possible carrier or infected to the best of my knowledge. I do voluntarily assume any and all reasonable 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.  Although exposure is unlikely, I accept the risk and consent to treatment.



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Patient/Parent ‘s Signature                                                       Date


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