STAFF ONLY Covid-19 Consent Form

  • Staff COVID-19 Form

  • DD slash MM slash YYYY
  • I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.
    I understand that certain dental procedures create aerosols which are one way that the novel coronavirus can spread.
  • By selecting all, I confirm that I am not presenting any of the following symptoms of COVOID-19 listed
  • I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to work on today's date during the COVID-19 pandemic. I understand that I may revoke this consent to provide dental treatment or assist with the provision of dental treatment at any time during the day. This means that I may change my mind.

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Thanks For Filling Out Our Form.

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