COVID-19 Emergency Treatment Consent and Release of Claims Form

Name*

First Last

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 even with the Practice following all the CDC and ADA guidelines for infection control of COVID-19 in providing emergency dental treatments, that I am still at risk for possible infection with receiving such treatment at the Practice at this time. (INITIAL)*

I understand that the treatment I am receiving is an emergency because of the underlying infection, pain, or condition that limits my normal day-to-day activities. I confirm I am seeking treatment for a condition that meets these criteria. (INITIAL)*

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 confirm that I, and those who live with me, have not displayed, or currently have, any of the symptoms that are representative of COVID-19, which are outlined above. (INITIAL)*

I confirm that, to the best of my knowledge, in the past 14 days I have not come into close contact with anyone who appeared to me as displaying, or having, any of the symptoms that are representative of COVID-19, which are outlined above. (INITIAL)*

I confirm, to the best of my knowledge, that I have not had close contact with an individual diagnosed with COVID-19 in the past 14 days.*

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 confirm that I, and those who live with me, have not returned in the last 14 days from traveling to any of the countries or regions with widespread ongoing transmissions, including all European countries, China, Korea, and Latin America. (INITIAL)*

RELEASE OF CLAIMS

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.

Patient Name*

First Last

Patient/Guardian Signature*

Date*

Witness Name*

First Last

Witness Signature*

Date*

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Martin Man, DMD

COVID-19 Emergency Treatment Consent and Release of Claims Form

RELEASE OF CLAIMS

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