COVID-19 Consent Form

COVID-19 Pandemic
Dental Treatment Consent Form


Even after following protocols set by the American Dental Association and the Georgia Dental Association, it is still possible to contract COVID-19 while at a dental office. We are following all guidelines to minimize the risk of transmission.

*I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic. I understand that the COVID-19 virus has a long incubation period during which carriers of this virus may not show symptoms and may still be highly contagious.

*I confirm that I am not presenting any of these COVID-19 symptoms:

  • Fever
  • Shortness of breath
  • Dry cough
  • Runny nose
  • Sore throat

*I confirm that I have not been in contact with a person who has been diagnosed with COVID19 within the past 14 days.

*I understand that – due to the frequency of visits of other dental patients, the characteristics of the COVID-19 virus, and the characteristics of dental procedures – I have an elevated risk of contracting the COVID-19 virus simply by being in a dental office.

*I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. The CDC recommends social distancing of at least six feet for a period of 14 days to anyone who has recently traveled and this is not possible with dentistry.

*Keeping staff & clients safe is our priority. By adding & upgrading materials & equipment (PPE) please be advised that there will be a $15 PPE fee that the American Dental Association is currently working to get covered under insurance.

*Printed Name (Patient)

*Date of Birth (Patient)

*Signature (Patient/Legal Guardian)

Date


We look forward to serving you,

The team at kksmiles.
​​​​​​​

VERY IMPORTANT: When we send you, your dentist, or any other healthcare professional an email, or you send us an email, the information sent is not encrypted. That means a third party may be able to access the information and read it since it is transmitted over the Internet. HIPAA stands for the Health Insurance Portability and Accountability Act HIPAA was passed by the U.S. government in 1996 in order to establish privacy and security protections for health information Information stored on our computers is encrypted. Most popular email services (ex. Hotmail®, Gmail®, Yahoo®) do not utilize encrypted email.

Email is a very popular and convenient way to communicate for a lot of people. In their latest modification to the HIPAA act, the federal government provided guidance on email and HIPAA. The guidelines state that if a patient has been made aware of the risks of unencrypted email, and that same patient provides consent to receive health information via email, then a health entity may send that patient personal medical information via unencrypted email.

By signing this document, you are giving us permission to send such information over the internet, unencrypted.

​​​​​​​If you would like more information on the HIPAA act: https://www.govinfo.gov/content/pkg/FR-2013-01-25/pdf/2013-01073.pdf

*Signature of Patient or Legal Guardian

CORONA VIRUS SCREENING QUESTIONNAIRE

Please fill-up the form below as this is required on every visit to our clinic.

*First Name

*Last Name

*Date of Birth

*Do you/they have a fever or have you/they felt hot or feverish recently (14-21 days)?

*Are you/they having shortness of breath or other difficulties breathing?

*Do you/they have a cough?

*Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

*Have you/they experienced a recent loss of taste or smell?

*Are you/they in contact with any confirmed COVID-19 positive patients?

*Is your/their age over 60?

*Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

*Have you been tested positive to COVID-19?

*Have you/they traveled in the past 14 days outside your state of residence?

Patients who are well but who have a sick family member at home with COVID-19 should consider postponing/rescheduling elective treatment. Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with dental treatment.

*Signature of Patient or Legal Guardian

VERY IMPORTANT: When we send you, your dentist, or any other healthcare professional an email, or you send us an email, the information sent is not encrypted. That means a third party may be able to access the information and read it since it is transmitted over the Internet. HIPAA stands for the Health Insurance Portability and Accountability Act HIPAA was passed by the U.S. government in 1996 in order to establish privacy and security protections for health information Information stored on our computers is encrypted. Most popular email services (ex. Hotmail®, Gmail®, Yahoo®) do not utilize encrypted email.

Email is a very popular and convenient way to communicate for a lot of people. In their latest modification to the HIPAA act, the federal government provided guidance on email and HIPAA. The guidelines state that if a patient has been made aware of the risks of unencrypted email, and that same patient provides consent to receive health information via email, then a health entity may send that patient personal medical information via unencrypted email.

By signing this document, you are giving us permission to send such information over the internet, unencrypted.

​​​​​​​If you would like more information on the HIPAA act: https://www.govinfo.gov/content/pkg/FR-2013-01-25/pdf/2013-01073.pdf

*Signature of Patient or Legal Guardian

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