COVID-19 Pandemic Emergency

Dental Treatment Consent Form

I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

    Please check all above that you confirmed
  • I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above listed emergency dental treatment completed during the COVID-19 pandemic.
  • Date Format: DD slash MM slash YYYY