NON-EMERGENT – COVID-19 PANDEMIC DENTAL TREATMENT NOTICE AND ACKNOWLEDGEMENT OF RISK FORM

This Covid-19 Informed Consent Form must be completed one time for each patient before your first appointment since the COVID-19 stay at home orders from the state of Minnesota. You may either fill it out online, sign and submit (left button) or download the paper form (right button) and bring the signed form to the office with you at your next appointment. Below is the information within the form.

COVID-19 Informed Consent Form Sign Online
Non Emergent: COVID-19 Informed Consent Form Sign on Paper

COVID-19 PANDEMIC DENTAL TREATMENT NOTICE AND ACKNOWLEDGEMENT OF RISK FORM

Our goal is to provide a safe environment for our patients and staff, and to advance the safety of
our local community. This document provides information we ask you to acknowledge and
understand regarding the COVID-19 virus.

The COVID-19 virus is a serious and highly contagious disease. The World Health Organization
has classified it as a pandemic. You could contract COVID-19 from a variety of sources. Our
practice wants to ensure you are aware of the additional risks of contracting COVID-19
associated with dental care.

The COVID-19 virus has a long incubation period. You or your healthcare providers may have
the virus and not show symptoms and yet still be highly contagious. Determining who is infected
by COVID-19 is challenging and complicated due to limited availability for virus testing.
Due to the frequency and timing of visits by other dental patients, the characteristics of the virus,
and the characteristics of dental procedures, there is an elevated risk of you contracting the
virus simply by being in a dental office.

Dental procedures create water spray which is one way the disease is spread. The ultra-fine
nature of the water spray can linger in the air for a long time, allowing for transmission of the
COVID-19 virus to those nearby.

You cannot wear a protective mask over your mouth to prevent infection during treatment as
your health care providers need access to your mouth to render care. This leaves you
vulnerable to COVID-19 transmission while receiving dental treatment.

I confirm that I have read the Notice above and understand and accept that there is an
increased risk of contracting the COVID-19 virus in the dental office or with dental treatment. I
further confirm that I understand and accept the additional risk of contracting COVID-19 from
contact at this office. I also acknowledge that I could contract the COVID-19 virus from outside
this office and unrelated to my visit here.