Appointment Check In

COVID-19 PANDEMIC TREATMENT CONSENT FORM

I, the patient, 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. Dental procedures take place with the patient in very close proximity to the service provider. Dental procedures create water spray 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 office. *

Initial Here:

I have been made aware of the guidelines under the current pandemic and I have elected to proceed with dental treatment at this time. *

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I confirm that I am not presenting any of the following symptoms of COVID-19 listed below:

+ Fever
+ Shortness of Breath
+ Dry Cough
+ Runny Nose
+ Sore Throat

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I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus as is being in close proximity to others. Social distancing of at least 6 feet is required for the prevention of spread. *

I confirm that I have taken all reasonable precautions for social distancing and have not travelled outside of the UK. Initial Here:

I understand that it is not possible to observe social distancing in dental treatment and I understand that there are possible risks of transmission of the virus. I accept this and wish to be treated at the present time. *

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I verify that I am happy follow social distancing rules and protocols implemented within Smileworks to protect myself and others. *

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Full Name: *

DOB: *

Contact Number: *

Monday	9.00am - 5.30pm
Tuesday	9.00am - 9.00pm
Wednesday	9.00am - 9.00pm
Thursday	9.00am - 9.00pm
Friday	9.00am - 5:30pm
Saturday	CLOSED
Sunday	CLOSED