COVID-19PANDEMICNOTICEANDACKNOWLEDGEMENT
OF RISK
The World Health Organization has characterized the
COVID-19 virus, also known as “Coronavirus,” as a pandemic. Our practice wants
to ensure you are aware of the risks of exposure to COVID-19 associated with
receiving treatment during this pandemic.
COVID-19 is highly contagious and has a long
incubation period. You or your healthcare providers may have the virus, not show
symptoms and yet still be highly contagious. COVID-19 can result in a
life-threatening respiratory disease in some patients. You may be exposed to
COVID-19 at any time or in any place. Due to the frequency and timing of visits
by other dental patients, the characteristics of the virus, and the
characteristics of dental procedures, there is an elevated risk of you
contracting the virus simply by being in a dental office.
Dental procedures can create fine water spray or
“aerosols” which may remain in the air for several minutes to hours. These
aerosols may contain the COVID-19 virus and may create a risk of COVID-19
exposure. You cannot wear a
protective mask over your mouth to reduce
exposure during treatment as your healthcare providers need access to your mouth
to render care. This leaves you vulnerable to COVID-19 transmission while
receiving dental treatment.
To provide a safe environment for our patients and
staff, this practice follows the applicable state and federal regulations and
protocols for infection control, universal personal protection, and
disinfection. However, due to the nature of the procedures we provide, it may
not be possible to maintain social distancing between patients, doctors, and
staff at all times.
Patient Acknowledgement
I acknowledge that I have read the Notice above and
that I understand and accept that there is an increased risk of COVID-19
exposure with treatment during the pandemic.
I understand and accept the increased risk of
COVID-19 exposure with treatment at this office.
I also acknowledge that I could, or may have,
exposure to COVID-19 from outside this office and unrelated to my visit
here.
I have read and understand the information stated
above:
Patient's Signature,