Dear Parents/Patient,
You have come to our office today for a routine dental evaluation and/or treatment that will
be done during the COVID-19 pandemic. Please be advised of the following:
While our
office complies with State Health Department and the Centers for Disease Control and
Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we
cannot make any guarantees.
Our staff are symptom-free and, to the best of their
knowledge, have not been exposed to the virus. However, since we are a place of public
accommodation, other persons (including other patients)could be infected, with or without
their knowledge. In order to reduce the risk of spreading COVID-19, we have asked you a
number of “screening” questions below. For the safety of our staff, other patients, and
yourself, please be truthful and candid in your answers.

I understand that due to the frequency of visits of other dental
patients, the characteristics of the virus, and the characteristics of dental procedures,
that I or my child has an elevated risk of contracting the virus simply by being in a dental
office.

I verify that my child does not have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders and
therefore does not have an increased risk of COVID19 related complications.

I understand that air travel significantly increases our risk of
contracting and transmitting the COVID-19 virus. Because the CDC recommends social distancing of
at least 6 feet for a period of 14 days to anyone who has, please note that this is not possible with
dentistry.

I confirm that I or my child are not presenting any of the following
symptoms of COVID-19 that includes Fever, Shortness of Breath, Dry Cough, Runny Nose, or a Sore Throat.

I confirm that I or my child has not lost sense of taste and/or smell

I verify that neither I nor my child has traveled outside of the United States
in the past 14 days to countries that have been affected by COVID-19.

I verify that neither I nor my child have traveled domestically within the
United States by commercial airline, bus, or train within the past 14 days.

If I cannot truthfully sign any of the above statements, the dentist
has strongly encouraged me to contact my primary physician or public health department to
determine if I should be seen or tested before coming in for any dental care.

This dental provider reserves the right to contact their local and
state health department authorities to report any patient suspected of having
COVID-19.

I give Smiles for Kids Pediatric Dentistry permission to treat my
child. This may involve examination, x-ray, and/or other tests. The treatment may
necessitate the usage of high-speed drills that produce aerosol. I understand that I will be in
close proximity to the doctor and other team members.

Purpose of Consent: By signing this form, you are knowingly
and willingly consenting to have dental treatment for your child completed during the COVID-19
pandemic.
I understand 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. Dental procedures
create a water spray which is how the disease is spread. The ultra-fine nature of the spray
can linger in the air for minutes to sometimes hours, which can transmit the COVID-19 virus.
We encourage you to read it carefully and completely before signing this Consent.

Child's Name

Your Name:

Signature for Covid