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.

  • I confirm that I am not presenting with any of the following symptoms of COVID-19 listed below:


                          Shortness of Breath

                          Dry Cough      

                          Runny Nose

                          Sore Throat    

                          Sudden loss of taste or smell


  • I verify that I have not traveled outside USA in the past 14 days. And that I have been following the self- quarantine and social distancing guidelines for the past 14 days minimum. I also have not been exposed to a CORONAVIRUS positive patient in the last 14 days, to the best of my knowledge.  (Initial)


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.


  • I understand that due to other dental patients visiting the office and due to the characteristics of the virus and dental procedures, I have an elevated risk of contracting the virus simply by being in a dental office. (Initial)
  • I have been made aware of the CDC and ADA guidelines that under the current pandemic all dental visits should be limited to the treatment of pain, infection or conditions that significantly impair normal function of teeth and mouth. (Initial)
  • I confirm I am seeking treatment for a condition that meets these criteria. (Initial)
  • I understand the CDC recommends social distancing of at least 6 feet, and this is not possible when seeking dental care. (Initial)





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Signed by Dr. Divya Sankepally
Signed On: Feb 3, 2022

Signature Certificate
Document name: COVID Release Form
lock iconUnique Document ID: 905d6d7ed74116972526c62e17aff200a24bec46
Timestamp Audit
Jul 28, 2020 7:15 pm CSTCOVID Release Form Uploaded by Dr. Divya Sankepally - IP