COVID-19 Treatment Consent Form

(patient) consent to receive treatment from Thomas G. Acierno, D.D.S. during the Covid-19 outbreak.
I understand there is much to learn about the newly emerged Covid-19 virus including how it spreads and 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 among close contacts. I] understand that close contact can occur from being within approximately 6 feet of someone with Covid-19 for a prolonged period of time or by having direct contact with infectious secretions from someone with Covid-19.
I understand that the 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 the practice and by receiving treatment in the practice.
I understand that the CDC and ADA guidelines don not recommend proceeding with any treatment that is non-essential 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 spread.
I understand that the symptoms listed below are representative of Covid-19:
  • Fever
  • Dry cough
  • Shortness of breath
  • persistent pain or
  • pressure in the chest
  • Loss of taste and/or
  • smell
  • Flu-like symptoms
  • Sore throat
I confirm that I do not display or currently have any of these symptoms that are representative of Covid-19, which are outlined above.
I understand that all travelers arriving from a country or region with widespread ongoing transmission, as outlined by the CDC, should stay home for 14 days to practice social distancing and monitor their health after their arrival.
I confirm that J have not traveled to any of the countries or regions with widespread ongoing transmission (level 3 Travel Health Notice) in the past 14 days.
I confirm, to the best of my knowledge, that have not had close contact with an individual diagnosed with Covid-19 in the past 14 days.