Consent to dental treatment during COVID-19
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I am aware that the current COVID-19 pandemic brings a number of known risks and a number of unknown risks. I have chosen to seek dental treatment during the pandemic in the knowledge that much is still unknown about the virus. *
In reading this I confirm that I understand that coronavirus that causes COVID-19 has a long incubation period during which time carriers of the virus may not show symptoms yet may be highly contagious. *
In reading this I confirm that I understand some people may have the virus but may not ever have any symptoms. *
In reading this I confirm that I understand it is impossible to determine who has the virus and I understand that I must assume that anyone anywhere could be infected and infectious. *
In reading this I confirm that I understand the risks and benefits of the treatment proposed as explained to me. *
In reading this I confirm that I understand there is no change in my COVID-19 status since this was last checked and that I will ensure to let the practice know if there is any such change. *
In reading this I confirm that I understand that receiving dental treatment means that the UK government’s instruction to maintain social distancing of at least 2 meters is not achievable during treatment. *
In reading this I confirm that I understand my dental practice and the team have taken every precaution to make sure my treatment is provided according to strict clinical protocols issued by NHS England and related guidelines. *
I consent to treatment being provided during the current lockdown phase of Covid-19. *
Which dentist will be treating you? *
Name of Patient *
Please state today's date. For example; 24th May 2020 *
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