Informed Consent During COVID-19
Patient Advisory and Acknowledgment
Receiving Dental Treatment During the COVID-19 Pandemic
Dear Patient Guardian:
You have presented to the office today to have your child receive dental care to prevent conditions which may become
progressively worse over time.
Please be advised of the following:
While our office complies with State Health Department and the Centers for Disease Control and Prevention infection control
guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees.
Our staff members are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a
place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge.
In order to reduce the risk of spreading COVID-19, we have asked you a number of “screening” questions.
We require the use of face mask/face covering by all persons entering the office. For the safety of our staff, other patients,
and yourself, we expect your answers have been truthful.