COVID-19 Pandemic Dental Treatment Consent Form


Even after following protocols set by the American Dental Association and our state’s dental association, it is still possible to contract COVID-19 while at a dental office. We are following all guidelines to minimize the risk of transmission.

  • I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic. I understand that the COVID-19 virus has a long incubation period during which carriers of this virus may not show symptoms and may still be highly contagious.  
  • I understand that – due to the frequency of visits of other dental patients, the characteristics of the COVID-19 virus, and the characteristics of dental procedures – I have an elevated risk of contracting the COVID-19 virus simply by being in a dental office.  
  • I confirm that I am not presenting any of these COVID-19 symptoms:
    • Fever
    • Shortness of breath
    • Dry cough
    • Runny nose (not associated with seasonal allergies)
    • Sore throat  
  • I confirm that I have not been in contact with a person who has been diagnosed with COVID19 within the past 14 days.  
  • I understand that air travel significantly increases my risk of contracting and transmitting theCOVID-19 virus. And the CDC recommends social distancing of at least six feet for a period of 14 days to anyone who has recently traveled, and this is not possible with dentistry.  
  • I verify that I have not traveled outside the United States in the past 14 days.  
  • I verify that I have not traveled domestically within the United States by commercial airline, bus or train within the past 14 days.  

Printed name:  

Date of birth:  

Leave this empty:

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Carolina Dentistry @ The Stateline https://statelinedental.com
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Document name: COVID-19 Pandemic Dental Treatment Consent Form
lock iconUnique Document ID: 81c68b31138d921061373792fa0d36b46c602945
Timestamp Audit
July 13, 2020 11:47 pm EDTCOVID-19 Pandemic Dental Treatment Consent Form Uploaded by Doctors Schwartz and Heidenreich - info@statelinedental.com IP 171.76.153.210
July 13, 2020 11:57 pm EDTFront Desk - info@statelinedental.com added by Dr. Jim Schwartz - info@statelinedental.com as a CC'd Recipient Ip: 104.139.96.140
July 13, 2020 11:57 pm EDTFront Desk - frontdesk.statelinedental@gmail.com added by Dr. Jim Schwartz - info@statelinedental.com as a CC'd Recipient Ip: 104.139.96.140