COVID-19 Informed Consent (Philadelphia Square)

I,*

, knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.

-----

In the past 14 days, have you or anyone you have been in contact with traveled outside of Butte County to areas that have been affected by COVID-19?*

Yes
No

If yes, where?

-----

In the past 14 days, have you or anyone you have been in contact with traveled domestically within the United States by commercial airline, bus, or train?*

Yes
No

If yes, where?

-----

Have you been tested for COVID-19?*

Yes
No

If yes, when were you tested?

If yes, was it for antibodies or virus?

If yes, what were your results?

-----

In the past 14 days, have you had any of the following signs or symptoms of COVID-19?

Fever*

Yes
No

Dry Cough*

Yes
No

Shortness of Breath*

Yes
No

Sore Throat*

Yes
No

In the past 14 days, have you knowingly been in contact with anyone showing signs or symptoms of COVID-19?*

Yes
No

-----

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.

-----

By checking this box below, I understand and agree to the above information. This will serve as my electronic signature for this COVID-19 Pandemic Dental Treatment Consent Form.*

I understand and agree to the above information

Date:

To request an appointment, please choose an office below

To pay a bill online, please choose an office below

COVID-19 Informed Consent

(PHILADELPHIA SQARE)

To request an appointment, please choose an office below