Treatment During COVID-19 Consent Form

I am aware that the current COVID-19 pandemic brings a number of known and unknown risks. I have chosen to seek dental treatment during the pandemic in the knowledge that much is still unknown about the virus.

I understand the coronavirus that causes COVID-19 has a long incubation period during which time carriers of the virus may not show symptoms yet still be highly infectious. I also understand that some people may have the virus but may not ever have any symptoms. I therefore understand it is impossible to determine who has the virus and I understand that I must assume that anyone anywhere could be infected and infectious

Name *

I confirm that I am not currently suffering from any of the following symptoms of Covid-19 and I have not suffered from any of these symptoms in the last 7 days. Please tick if applicable: *

• Fever (a temperature of 37.8 degrees centigrade or above).
• A new persistent dry cough.
• Loss of taste and/or smell

I confirm that I have not been in close contact (within 2 metres) of anyone suffering with any of these symptoms in the last 14 days.... Signed Patient/ Parent/ Guardian : *

I understand that receiving dental treatment means that the UK government’s instruction to maintain social distancing of at least 2 metres is not achievable during treatment........Signed Patient/ Parent/ Guardian : *

I understand that some people are considered to be at greater risk of serious illness or higher mortality if they contract COVID-19 and I understand that these are individuals who: (Please indicate if applicable) *

• Have pre-existing medical conditions such as heart and circulatory disease.
• Have high blood pressure.
• Have diabetes.
• Are very overweight.
• Are male.
• Are over 60 years of age.
• Are from a black, Asian or minority ethnic (BAME) background.

I understand that my dentist at Bear Cross Dental Practice will take every precaution to make sure my treatment is provided according to strict clinical protocols and hygiene procedures. Signed Patient/ Parent/ Guardian: *

I consent to the treatment being provided during the current phase of Covid-19 *

Date: *

Patient/ Parent/ Guardian Signed: *