COVID-19 Consent Form Your DetailsName* MrMrsMissMsDrProf.Rev. Prefix First Last Email*To receive a copy of this form please enter your email Enter Email Confirm Email DOBDay12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920COVID-19 Dental Treatment ConsentConsent* I understand that I am opting for an elective dental consultation/treatment/procedure.*Consent* I understand that the novel coronavirus, the World Health Organisation has declared COVID-19, a worldwide pandemic and that COVID-19 is extremely contagious and believed to spread by person to person contact; and, as a result social distancing is recommended. This is not entirely possible with my proposed treatment. However, I am satisfied that safety measures are in place to minimise risks much as possible. Patient contact will be kept to an absolute minimum in line with medical need.*Consent* 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. I understand that COVID-19 can cause additional health risks, some of which may currently not be known at this time, in addition to those risks associated with dental consultation/treatment/procedure itself*Consent* I have been given the option to defer my dental consultation/treatment/procedure to a later date. However, I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19 and I would like to proceed with my desired dental consultation/treatment/procedure*I confirm that I am not presenting with any of the following symptoms of COVID-19 listed below: • Fever • Shortness of breath • Loss of sense of taste or smell • Dry cough • Runny nose • Sore throat Consent* I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. I confirm that I have not travelled in the past 15 days.** I confirm that if I develop COVID-19 symptoms following my dental appointment or a known contact of mine develops symptoms, I will immediately inform the practice to enable appropriate measures to be put in place and contact tracing to commence*Signature*Date of Signature NameThis field is for validation purposes and should be left unchanged.
