Covid 19 Form

Dental Treatment Consent Form during the Covid-19 Pandemic

Patient Name *

At Royal House Dental Centre your wellbeing is our highest concern.

I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus maynot show symptoms and still be contagious. This means you may meet people at the practice who are unaware they have the virus. I understand that some dental procedures create a water spray and it is possible that this is one way that the novel coronavirus can spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, and this may transmit the novel coronavirus. I understand that despite Royal House Dental Centre following the most up to date and stringent infection control procedures, due to the frequency of visits of other dental patients, the characteristics of the novel coronavirus, and the characteristics of dental procedures, I have an increased risk of contracting the novel coronavirus simply by being in a dental practice. I confirm that I am not presenting any of the following symptoms of COVID-19 identified by the NHS I confirm that I am not in a high-risk category, including: diabetes, cardiovascular disease, hypertension, lung diseases including moderate to severe asthma, being immuno- compromised, having active malignancy

OR

I fall into the following high-risk category and my dentist and I have discussed the risks, and I agree to proceed with treatment. I confirm that I am not currently positive for the novel coronavirus. I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus. I confirm that I have not travelled abroad in the past 14 days. I understand that any travel from any country outside of the UK, including travel by car, air, bus or train, significantly increases my risk of contracting and transmitting the novel coronavirus. I understand that Public health England (PHE) has asked individuals to maintain physical distancing of at least 1 metre (3 feet) and it is not possible to maintain this distance and receive dental treatment. I verify that I have not been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by the NHS, Public health England or any other governmental health agency. I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above listed dental treatment completed during the COVID-19 pandemic. I consent to my details being held in accordance with the GDPR protocols of the practice which are available on our website phpstack-337589-2910257.cloudwaysapps.com