• I consent to receive emergency treatment from [Practice Name] during the COVID-19 outbreak.

    I understand there is much to learn about the newly emerged COVID-19, including how it spreads and is transmitted.

    I understand that, based on what is currently known about COVID-19, the spread is thought to occur mostly from person-to-person via respiratory droplets during close contacts. I understand that close contact can occur from being within approximately 6 feet of someone with COVID-19 for a period of time, or by having direct contact with infectious secretions from someone with COVID-19.

    I understand that carriers of COVID-19 may not show symptoms but may still be highly contagious.

    I understand that due to the unknowns of this virus; the number of other patients that have been in the Practice; and the nature of the procedures performed here; that I have an increased risk of contracting the virus by being in, and by receiving treatment at, the Practice.

    I understand that the Center for Disease Control (“CDC”) and American Dental Association (“ADA”) guidelines do not recommend proceeding with any treatment that is non-emergency at this time.

  • I understand that dental procedures have the potential to include aerosol-generating procedures as well as anticipated splashes and sprays, which are some of the ways that COVID-19 can be spread.

    I understand that the symptoms listed below are representative of COVID-19:

    • Fever
    • Dry Cough
    • Shortness of Breath
    • Temperature
    • Persistent pain or pressure in the chest
    • Bluish lips or face
  • I understand that all travelers arriving from a country or region with widespread ongoing transmissions should stay home for 14 days to practice social distancing and monitor their health after their arrival.

    I release, that is, I give up and forever relinquish any and all claims, complaints and any legal actions in any court of law, or in any other proceedings before any governmental entity, that I became infected with the coronavirus, or that I suffered any other personal, physical or any other injury as a result of the emergency dental treatment I have received from the Practice and from all the professional and technical providers who treated me at the Practice. I understand this release means that I can never bring any claim for any money damages, nor for any other legal remedy/relief against the Practice and any of the professional and technical providers at the Practice.

    I acknowledge that I have read and understand this Release and that I knowingly and voluntarily have signed it as a condition of the Practice agreeing to provide emergency treatment for me.

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