COVID-19 Pandemic Dental
Treatment Consent Form

Patient Name *

First

Last

Date of Birth *

Gender *

Phone *

Email *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Patient Acknowledgement

I understand that the novel coronavirus causes the disease known as COVID-19.
I understand that the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not, given the current limits in virus testing.
I confirm that to my knowledge I am not currently positive for the novel coronavirus. I confirm that I am not waiting for results of a laboratory test for the novel coronavirus that was ordered due to contact tracing or because I had identified risk factors.
If I am an asymptomatic carrier or an undiagnosed patient with COVID-19, I suspect it may endanger doctors and clinic staff. It is my responsibility to take appropriate precautions and to follow the protocols prescribed by them.
I am aware that I may get an infection from the clinic or a doctor, and I will take every precaution to prevent this from happening, but I will not hold doctors and clinic staff accountable if such infection occurs to me or my accompanying persons.
In case, I or my attendant get the COVID-19infection after the visit to the clinic, I will inform the clinic authorities at the earliest, so that appropriate tracking of the patients/attendants and clinic staff present on the day of my visit can be done.
I confirm that I am not presenting any of the following symptoms of COVOID-19: fever or chills; cough; shortness of breath or difficulty breathing; fatigue; muscle or body aches; headache; new loss of taste or smell; sore throat; congestion or runny nose; nausea or vomiting; diarrhoea. This list does not include all possible symptoms. Smile Mantra will continue to update this list as we learn more about COVID-19.
I understand the government recommends social distancing of at least 6 feet for 14 days to anyone who has shown symptoms or tested positive.
I verify that I have not been in any location/resided in/travelled to any containment zone or hotspots as designated by the government/health authorities and/or any other place potentially infected with the coronavirus as recognised by the government or health authority.
I verify that I have not been in direct contact with or near any person who I knew and/or now known to be infected with the coronavirus and/or as a potential carrier of the coronavirus or has been identified to be suffering from symptoms of the coronavirus.
I acknowledge and accept that this declaration shall be deemed to be my consent for Smile Mantra Dental & Cosmetic Clinic to store, record and report this declaration with the government or health authorities as may be necessary to prevent the further spread of the coronavirus.

Signature *

Use your mouse or finger to draw your signature above

Checkbox 1 *

I hereby give my consent to Smile Mantra Dental and Cosmetic Clinic to conduct the required dental & cosmetic procedures on me during the COVID-19 pandemic.

I state that all information provided by me in this Declaration & Consent Form is true and correct to the best of my knowledge and belief. If I hide my facts and relevant details and because of my knowledge or unknowing behaviour or action the clinic staff gets infected, I may be held responsible for appropriate compensation in the court of law.

COVID-19 Pandemic Dental
Treatment Consent Form

Patient Acknowledgement

Start Smiling Now

Smile Mantra^®
Dental and Cosmetic Clinic

Address

Working Hours

COVID-19 Pandemic Dental Treatment Consent Form

Patient Acknowledgement

Start Smiling Now

Smile Mantra® Dental and Cosmetic Clinic

Address

Working Hours

COVID-19 Pandemic Dental
Treatment Consent Form

Smile Mantra^®
Dental and Cosmetic Clinic