Consent to Dental Treatment during COVID-19

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.

I understand the coronavirus that causes COVID-19 has a long incubation period during which time carriers of the virus may not show symptoms yet still be highly contagious. I also understand that some people may have the virus but may not ever have any symptoms. I therefore 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.

I confirm that I (and/or my guardian) am not currently suffering from any of the following symptoms of Covid-19 and I have not suffered from any of these symptoms in the last 7 days

* Fever (a temperature of 37.8 degrees centigrade or above).
* A new persistent dry cough.
* Muscle pains.
* Headache.
* Shortness of breath and breathing difficulties.
* Severe pneumonia.
* Loss of taste and/or smell.
* Extreme fatigue.
* Runny nose.
* Sore throat

I confirm that I have not been in close contact (within 2 metres) of anyone suffering with any of these symptoms in the last 14 days.

I understand that receiving dental treatment means that the UK government’s instruction to maintain social distancing is not achievable during treatment.

I understand that the Dentist at Finedon Dental Practice has taken every precaution to make sure my treatment is provided according to strict clinical protocols issued by NHS England; CDO (SOPs’)

I confirm that I understand the risks and benefits of the treatment proposed as explained to me by the Dentist at Finedon Dental Practice and all my questions have been answered to my satisfaction and by signing below I consent to the treatment being provided during the current phase of Covid-19

Patient’s name:

Date:

Guardian Name (If applicable):

COVID-19 Screening Form

PREAPPOINTMENT CHECKIN-OFFICE VISIT

1. Have you had your Covid-19 vaccinations?
YesNo

If Yes, Number of Vaccinations received:

2. Have you previously been diagnosed with COVID-19?
YesNoI think I have itI have it now

(If NO to question 2, skip to question 6)

3. If YES, when and how were you confirmed positive?N/AI think I had it.I had a positive Lateral Flow test.I had a positive PCR test.I currently have symptoms and am waiting for a test.

Date:

4. If you have had COVID-19, when were you confirmed negative? N/A24 hours agotoday10 days after testing

5. If you have had COVID-19, how were you confirmed negative?N/AI was diagnosed negative by a nasal swab test.I show antibodies to COVID-19 with a blood test.My doctor said I no longer have it because I don’t have any symptoms.I don’t have any symptoms, so I don’t have it

6. Are you in contact with anyone who has been sick and/or confirmed to be COVID-19-positive in the last 10 days?
YesNo

7. Have you been contacted by NHS track and trace in the last 10 days?
YesNo

8. In the past 14 days have you travelled to any regions affected by COVID-19?
YesNo

9. Do you currently have (or have you experienced) any of the following symptoms in the past 21 days:

10. Are you in contact with anyone who has been sick and/or confirmed to be COVID-19–positive?YesNo

11. In the past 14 days have you traveled abroad and/or to any regions affected by COVID-19? YesNo

If yes, please state where:

Some medical conditions have been associated with more severe COVID-19 disease. The following questions are an attempt to determine your risk:

Do you have or have you ever had any of the following:

Are you taking immunosuppressive drugs for:

Please leave this field empty.