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Consent to dental treatment during Covid-19

By: | Tags: | Comments: 0 | November 14th, 2020

I am aware that the current Covid-19 Pandemic brings a number of known risks and a number of 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 corona virus that causes Covid-19 has a long incubation period during which time carriers of the virus may not show symptoms yet still be highly contagious. 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…………..Initial.

I confirm I am seeking treatment for …………………………..and …………………………….has agreed to provide treatment because …………………..Initial.

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…………………..Initial.

  • Fever ( a temperature of 37 degrees centigrade or above.
  • A new persistent dry cough
  • Flu like symptoms
  • Muscle pain, headaches, shortness of breath and breathing difficulties.
  • Severe pneumonia, loss of taste and/or smell,
  • extreme fatigue, runny nose and sore throat

I confirm that I have not been in close contact ( within 2 meters) of anyone suffering with any of these symptoms in the last 14 days…………………….initial.

I understand that receiving dental treatment means that the UK government’s instructions to maintain social distancing of at least 2 meters is not achievable during treatment……………………………………..initial.

I understand that ………………………………………………….has taken every precaution to make sure my treatment is provided according to strict clinical protocols issued by NHS England………………………………………..Initial.

I consent to the following treatment:

………………………………………………………………………….Initial.

I consent the treatment provided during the current lockdown phase of Covid-19

Name………………………………………………………………Date……………………………………………..

Signature………………………………………………………………….

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