COVID form

COVID

Screening/Disclosure Form for Dental Patients During Covid-19 Epidemic


    The above information given by me is true to the best of my knowledge. I fully understand and acknowledge that withholding or mis-representation of any information is highly unethical and against the interest of larger population during this pandemic.


    I have been made aware that dental procedures create ultra-fine water spray that may transmit the Covid-19 virus. 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 also understand that, due to the contagious nature of the disease and characteristics of dental procedures, I have an increased risk of contracting the virus simply by being in a dental office in spite of the best disinfection protocols applied.


    I fully understand and acknowledge that I may be an asymptomatic carrier of the disease and hence will strictly comply with all safety precautions and protocols advised. In the eventuality of my testing covid positive at a later date, I will not hold the dental service provider/staff/dental set-up responsible for it. I hereby knowingly and willingly give consent to have my emergency / urgent dental treatment completed during the Covid pandemic.

    Signature of patient:

    Staff Signature