General Dental Treatment Consent Form COVID-19 Pandemic


  1. I knowingly and willingly consent to dental treatment by Dr. and any designated associates and employees during the COVID-19 Pandemic.
  2. I understand the Dr.   is following CDC guidelines as far as treatment protocols and infection control.
  3. I am aware of being a possible carrier or infected: I confirm that I have not tested positive for COVID-19 in the last 30 days and that I am not presenting with any of the following symptoms of COVID-19:
    1. Fever of 100.5 degrees Fahrenheit or 37 degrees Celsius or higher
    2. Shortness of breath
    3. Dry cough
    4. Runny nose
    5. Sore throat
    6. Diminished sense of taste and smell
  4. Contact with infected: I confirm that I have not knowingly been in close contact defined as 6 feet or less for a duration of 15 minutes or more with someone who has tested positive for COVID-19 in the last 14 days, or with anyone who has had the above stated symptoms in the last 14 days.
  5. Public Travel: I confirm that I have not traveled outside of the Untied Sates in the last 14 days. I confirm that I have not traveled domestically by commercial airline, bus, or train within the last 14 days.
  6. I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms yet are still highly contagious. It is impossible to determine who has it and who does not give the current limitations and availability in COVID-19 testing.
  7. Risk of transmission: I understand that due to the frequency of visits to other dental patients, characteristics of the virus, and the characteristics  of dental procedures, that I may have an elevated risk of contracting the virus simply by being in a dental office, even though CDC and Utah Department of Health guidelines are being observed. 
  8. INFORMED CONSENT:  I have been given the opportunity to ask any questions regarding the risk of contracting COVID-19 from the dental office and dental procedures. I reaffirm that I am not a carrier of COVID-19 nor infected with COVID-19 to the best of my knowledge. I do voluntarily assume any and all responsible medical/dental risks, including the substantial and significant risk of serious harm, if any, which may be associated with any phase of treatment as a result of the COVID-19 pandemic. I acknowledge that the nature and purpose of the dental procedures recommended have been explained to me if necessary and I have been given the opportunity to ask questions.
 
Patients Name:

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Signed by Marlo Dillman
Signed On: May 6, 2020

Altaview Dental Care and Headache Relief Center https://altaviewdental.com
Signature Certificate
Document name: General Dental Treatment Consent Form COVID-19 Pandemic
Unique Document ID: 66eb783989627257547967ec736903f7a2d4a25e
Timestamp Audit
May 6, 2020 11:53 am MDTGeneral Dental Treatment Consent Form COVID-19 Pandemic Uploaded by Marlo Dillman - [email protected] IP 73.20.14.12