Covid-19 screening and consent form for patients

Name:*

First NameLast Name

Date of Birth:*

Date

Are you experiencing any of the following symptoms?*

High temperatureA new continuous coughLoss or change to your sense of smell or tasteI AM NOT EXPERIENCING ANY OF THE ABOVE SYMPTOMS

Are you / have you / do you*

Waiting for a coronavirus test result?Tested positive for coronavirus?Live with someone who has symptoms, is waiting for a test result or has tested positiveBeen told by the NHS Test and Trace service that you've been in contact with a person who has coronavirus (COVID-19) within the last 14 days?Travelled from outside the UK in the last 14 days?NONE OF THE ABOVE

Are you, or do you have, any of the following?*

Due to you being / having, you are at higher risk and clinically vulnerable to Covid-19 infection.

We would recommend you delay any elective treatment

I, {name3}, understand that I am opting for an elective dental treatment/procedure/surgery.

I understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization and that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, social distancing is recommended. This is not entirely possible with my proposed treatment, however, I am satisfied that safety measures are in place to minimise risk as much as possible, and patient contact will be kept to an absolute minimum in line with dental need.

I understand the Management and Clinical Staff are closely monitoring the COVID-19 situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19. However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective dental treatment/procedure/surgery, and I give my express permission to proceed.

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. I understand that COVID-19 can cause additional health risks, some of which may not currently be known at this time, in addition to those risks associated with the dental treatment/procedure/surgery itself.

I have been given the option to defer my dental treatment/procedure/surgery to a later date. However, I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with the dental treatment/procedure/surgery.

I confirm that I am not presenting with any of the following symptoms of COVID-19 listed below:

· Fever

· Shortness of Breath

· Loss of Sense of Taste or Smell

· Dry Cough

I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. I confirm that I have not travelled in the past 14 days

{signature267}

{name3}{date}

Signature*

Date:

DayMonthYear

Please do not attend your appointment, go home and self-isolate