COVID-19 Informed Consent 

(Glenbrook Office)

  • , knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.
  • • In the past 14 days, have you had any of the following signs or symptoms of COVID-19?
  • -----

    I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. The CDC recommends social distancing of at least 6 feet for a period of 14 days to anyone who has been traveling, and this is not possible with dentistry.

    I willingly and knowingly elect to have treatment done and hold Kremer Dental Care, its doctors and its staff harmless. I understand, if I were to contract and test positive with COVID-19, I cannot prove that it was related to or associated with my visit to the dental practice. For this reason, I understand the dental practice is helping me with dental care and is held harmless against any COVID-19 affects that may occur in my lifetime. I understand the dentist and his dental practice use standard precautions and disinfecting protocol to minimize any such risk to themselves and all patients.

  • Date Format: MM slash DD slash YYYY
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