COVID CONSENT FORM

  • Covid-19 Pandemic Dental Treatment Questionnaire

  • CMOH Order 05-2020 legally obligates any person who has the following 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 sympotoms resolve, whichever takes longer. If you are exhibiting any of these symptoms, it is suggested you complete the COVID-19 Self-Assessment online tool to determine if you should be tested.
  • Please click to confirm you have read understand all the below:
  • 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.

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