COVID Supplemental Consent Pediatric Dental Treatment in the Era of COVID-19Our goal is to provide a safe environment for our patients and team members. This document provides information that we ask you to acknowledge and understand regarding the COVID-19 virus.Thank you for the continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as “Coronavirus” at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so.The COVID-19 virus has a long incubation period. You, your child, or your healthcare providers may have the virus and not show symptoms and yet still be highly contagious. Determining who is infected by COVID-19 is challenging.Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favorite restaurant. “Social Distancing” nationwide has reduced the transmission of the Coronavirus. Although we have taken measures to provide social distancing in our practice due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, the pediatric dentist or hygienist, pediatric dental staff, and sometimes other patients at all times.Do you accept the risk and consent for treatment?*YesNoName* First Last Signature of Parent/Legal Guardian*Date* Date Format: MM slash DD slash YYYY Have you, your child, others accompanying you to today’s appointment or anyone you have recently been in contact with tested positive for or been diagnosed as having COVID- 19 or any other communicable disease?*YesNoIf yes, provide approximate date of illness* Date Format: MM slash DD slash YYYY If so, I understand it may be possible that I will be asked to reschedule my appointment. INITIAL*CAPTCHA If you have an issue submitting this form, please download our paperwork here and call our staff to discuss how you can submit it.