Thank you for your continued trust in our practice.

As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as “coronavirus” at any time or in any place. Be assured that we continue to follow state and federal regulations as well as recommended universal personal protective equipment (PPE) and disinfection protocols to limit all diseases in our office. Despite our careful attention to sterilization, disinfection and the use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be exposed at your gym, grocery store or favorite restaurant. Nationwide social distancing has reduced the transmission rate of the coronavirus. Although we have taken measures to enable social distancing in our practice, it is not possible to maintain social distancing between the patient, dental healthcare team members and sometimes patients at all times.

Although exposure is unlikely, do you accept the risk and consent to treatment?

do you accept the risk and consent to treatment?(Required)
Patient Name(Required)
(If applicable)
To finish the process you must put a digital signature or name indicating you have read and agree to the above document.
Reset signature Signature locked. Reset to sign again
This field is for validation purposes and should be left unchanged.