COVID-19 Dental Treatment Consent Form

  • CMOH Order 05-2020 legally obligates any person who has a cough, fever, shortness of breath, runny nose, or sore throat (that is not related to a pre-existing illness or health condition) to be in isolation (quarantine) for 10 days from the start of symptoms, or until symptoms resolve, whichever takes longer or they receive a negative COVID test

  • For Patients OVER 18, please confirm that you’re not presenting any of the following core symptoms of COVID
  • For Patients UNDER 18, please confirm that you’re not presenting any of the following core symptoms of COVID
  • There are categories of people who are considered to be high risk. I understand some high-risk category factors are being 65 years of age or older, heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorder.
  • I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above listed dental treatment completed during the COVID-19 pandemic