Consent to dental treatment during COVID-19
I, , knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.
I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing.
All dental procedures create water spray(aerosol) which is how the disease is spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the COVID-19 virus.
- I understand that due to the frequency of visits of other dental patients, the characteristics of the virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the virus simply by being in a dental practice.
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
- Fever (a temperature of 37.8 degrees centigrade or above).
- A new persistent dry cough.
- Muscle pains.
- Shortness of breath and breathing difficulties.
- Severe pneumonia.
- Loss of taste and/or smell.
- Extreme fatigue.
- Runny nose.
- Sore throat
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
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
I consent to the treatment being provided during the current lockdown phase of Covid-19
Confidential Medical History Form
Have you tested positive for COVID-19?
Have you a raised temperature or fever? (Feel hot to touch on your chest/ back)
Do you have a new continuous cough? (1hr recurrently or 4+ episodes/24hr)
Do you have partial/total loss of your sense of smell or taste?
Have you been isolating with symptoms in the past 14 days?
Are you or the household self-isolating?
Have you been in contact or does anyone in your household exhibit any flu like symptoms?
Are you in a vulnerable group or at increased risk of serious illness from COVID-19?
Are you currently attending or receiving treatment from a doctor, hospital or specialist?
Are you pregnant or a nursing mother?
Are you currently taking any prescribed medicines, tablets, drugs or injections or using any creams, ointments or inhalers?
Are you carrying a medical warning card?
Do you suffer from allergies to any medicines, food, substances or materials? (e.g. Penicillin, Latex/Rubber)
Do you suffer from hay fever or eczema?
Do you suffer from asthma, bronchitis or other chest conditions?
Do you suffer from fainting attacks, giddiness, blackouts or epilepsy?
Do you suffer from heart problems, angina, blood pressure problems or stroke?
Are you a diabetic (or is anyone in your family)?
Do you suffer from arthritis?
Do you suffer from bruising or persistent bleeding following injury, tooth extraction or surgery?
Do you suffer from any infectious diseases, including HIV and hepatitis?
Have you ever had rheumatic fever or chorea?
Have you ever had liver disease (e.g. jaundice, hepatitis) or kidney disease?
Have you ever had any other serious illness?
Have you ever had your blood refused by the Blood Transfusion Service?
Have you ever had a bad reaction to local or general anaesthetic?
Have you ever had a joint replacement or other implant?
Have you ever had treatment that required you to be in hospital?
Have you ever had heart surgery or do you have a pace maker?
Have you ever had brain surgery?
Did you receive growth hormone treatment before the mid 1980’s?
Do you have any close relatives with Creutzfeldt Jakob Disease?
Are you taking or have you ever taken Alendronic Acid or Bisphosphonates?
Do you consume any alcohol? (If so, how many units do you consume per week?)
Do you smoke any cigarettes? (if so, how many per day)
Do you smoke or chew any tobacco products, pan, use gutka or supari?
Is there any other information which your dentist might need to know about, such as self-prescribed medications? (i.e. Aspirin)
DentalHouse will never give your information to a third party for marketing purposes. We will only share relevant information from your dental records with other professionals when clinically required, for example when we need to refer you to hospital or specialist services.
To indicate consent please enter the following details: