Notice and Acknowledgement Form

                                                  

                                                               COVID‐19 PANDEMIC DENTAL TREATMENT NOTICE AND
                                                                                 ACKNOWLEDGEMENT OF RISK FORM

Our goal is to provide a safe environment for our patients and staff, and to advance the safety of our
local community. This document provides information we ask you to acknowledge and understand
regarding the COVID‐19 virus.

The COVID‐19 virus is a serious and highly contagious disease. The World Health Organization has
classified it as a pandemic. You could contract COVID‐19 from a variety of sources. Our practice wants to
ensure you are aware of the additional risks of contracting COVID‐19 while receiving dental care.

The COVID‐19 virus has a long incubation period. You or your healthcare providers may have the virus
and not show symptoms and yet still be highly contagious. Determining who is infected by COVID‐19 is
challenging and complicated due to limited availability of virus testing.

Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and
the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by
being in a dental office.

Dental procedures create water spray which is one way the disease is spread. The ultra‐fine water spray
can linger in the air for a long time, allowing transmission of the COVID‐19 virus to those nearby.
You cannot wear a protective mask over your mouth to prevent infection during treatment as your
health care providers need access to your mouth to render care. This leaves you vulnerable to COVID‐19
transmission while receiving dental treatment.

I confirm that I have read the Notice above and understand and accept that there is an increased risk of
contracting the COVID‐19 virus in the dental office or with dental treatment.  I understand
and accept the additional risk of contracting COVID‐19 from contact at this office. I acknowledge that I
could contract the COVID‐19 virus outside of this office in circumstances unrelated to my visit here.

I have read and understand the information stated above:

__________________________________                   __________________________________                     ______________
Signature                                                                   Witness                                                                         Date

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12:00 PM-7:00 pm

Tuesday:

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Wednesday:

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Thursday:

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Friday:

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Sunday:

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