Current!studies!indicate!that!some!dental!procedures!create!aerosolized!particles!(similar!to!a!sneeze)!of!the!
virus!that!causes!COVID-19,!which!ca n !linger!in!the!a ir!f o r!minutes!to !som etim es!hours,!wh ich!can!result!in!
transmission!of!CO VID - 19!(Coronavirus)!from!an!infected!person.!!
I!understan d !a nd !a c kn o wledge!this!inform a tion!and!hereby!declare!that!I!have!a!dental!condition!that!
requires!prompt!ca re!or!I!have!a!child!with!a!dental!condition!that!requires!prompt!care.!!
___________!(Initial)!!
I!hereby!affirm!that!my!de n t ist /s u rg eo n !a n d !anesthesiologist!have!discussed!with!me!the!preventative!
measures!being!taken!to!minimize!the!risk!of!COVID-19!(Coronavirus)! tra ns m ission .!
___________!(Initial)!
I!fully!underst a n d!t h a t!p ro c ee d in g !w it h !th e !tre a tment!today!in c re a se s !m y !e xp o s u re /my!child’s!exp o su r e!and!
therefore!my!risk!of!con tractin g!co m m u nity!a cqu ired !CO V ID- 19!(Coronavir u s)!in fe ctio n .!
Acquiring!such!infection!can!lead!to!symptoms!such!as!fever,!chest!pain,!shortness!of!breath!and!further!
respiratory!complica tion s.!Severe!disease!can!also!lead!to:!prolonged!hospitalization,!intensive!care!
admission,!mechanical!ventilation,!and/or!possible!death.!!
I!also!affirm!th a t!n e ith e r!I/ my!child,!nor!any!of!my!immediate!fam ily!m e m b ers!ha ve !bee n !exp ose d!to !or!had!
any!of!the!following!symptoms!in!the!past!14!days:!
1)!Fever!(≥100.4°!F)
2)!Shortness!of!breath
3)!Dry!cough
4)!Fatigue!and!body!aching
5)!Chest!pain
6)!Confirmed !or!sus pe cted !CO V ID -19!(Coronavirus)!infection
I am consenting to this procedure with full understanding and disclosure of such risks and
alternatives, and all my questions were answered to my satisfaction.
Name!(printed):!_______________________________________________________________________!
Signature:!____________________________________________________________________________!
Relationship!to!patient!(if!applicable):!______________________________________________________!
Date:!___________________________!
