COVID Consent Form Division Family Dental

Division Family Dental

2484 NE Division St, Gresham Or 97030

503-676-3439

COVID-19 Patient Waiver and Consent Form

I (or my child/ward),

knowingly and willingly consent to receive dental treatment during the COVID-19 pandemic.

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in the virus testing

Dental procedures create water spray. It is unclear as to how long the ultra-fine nature of the spray may linger in the air, which can transmit the COVID-19 virus.

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

Fever (including low grade fever), fatique, body aches
Dry cough, sore throat
Shortness of breath or difficulty breathing
Chills, repeated shaking with chills
Muscle pain
Headache, sore throat
New loss of taste or smell
Trouble breathing, bluish lips or face

I understand that the CDC recommends social distancing of at least 6 feet to any individual not living in my household, and this is not possible with dentistry.

I confirm that if I test positive or advised presumptive positive by a medical professional within 14 days of receiving treatment, I will immediately notify the practice.

I confirm that I have not traveled on a cruise ship in the past 14 days.

I confirm, to the best of my knowledge, that I have not had close contact with an individual diagnosed with COVID-19 in the past 14 days.

Date: 4/25/2024 Patient or Parent/Guardian Signature

Date: 4/25/2024 Dentist Signature

Date: 4/25/2024 Witness Signature

Date: 4/25/2024 Interpreter Signature