Covid-19 Consent Form


  • DD slash MM slash YYYY
  • I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.
    I understand that dental procedures create water and/or blood spray which is one way that the novel coronavirus can spread.
  • By selecting all, I confirm that I am not presenting any of the following symptoms of COVOID-19 listed
  • I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.

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