COVID Release Form
COVID-19 Dental Treatment Consent Form
I, , consent to have dental treatment during the COVID-19 pandemic at this office. I have also been verbally informed of the risks.
Shortness of Breath yesno
Dry Cough yesno
Sore Throat yesno
Sudden loss of taste or smell yesno
I understand that this office screens all patients and staff for possible COVID-19 infection per the current guidelines. However, carriers of the virus may be completely asymptomatic and still be contagious. Some may never develop full blown symptoms. Presently, it is impossible to determine who is an asymptomatic carrier. While this office strictly adheres to the OSHA/WISHA standards as they currently exist, Coronavirus is a new, highly contagious pathogen that can be transmitted to and from healthcare workers even under strictly followed OSHA/WISHA standards. This virus can be spread through droplets or contact. Additionally, certain Dental procedures create water mist (aerosol) which is one way the virus is spread. The aerosol and thus the virus can linger in the air for hours after certain dental procedures.
Leave this empty:
Your legal name
Your email address
Signed by Dr. Divya Sankepally
Signed On: Feb 3, 2022
If you have questions about the contents of this document, you can email the document owner.
Document Name: COVID Release Form
Agree & Sign