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
Mobile phone number:
Confidential Medical History Form
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:
Date of Birth