COVID-19 Pandemic Dental Treatment Patient Consent Form

Issued in the interest of self-protection of the patients and dental personnel

Please note that this form should be completed and returned to us within 24 hours of EACH visit.

Patient Name*

Prefix First Last

Date of birth*

Email*

If completed on behalf of a minor, please state your name here:

First Last

I consent to treatment*

I knowingly and willingly consent or for myself or for a minor under my care to have dental treatment 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 per patient/person.

Dental procedures take place with the patient in very close proximity to the service provider. This potentially exposes the patient and the operator to saliva and to coolant water spray, which may spread the disease. The ultra-fine nature of the spray and droplets may linger in the air for minutes to sometimes hours, which can transmit the COVID-19 virus.

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 have an elevated risk of containing the virus simply by being in a dental office.

I have been made aware of the National Institute of Communicable Diseases (NCID) guidelines that under level 4 and 5 pandemic lockdown all elective procedures is not recommended. Dental visits should ideally be limited to the treatment of pain, infection, conditions that significantly inhibit normal operation of teeth and mouth, and issues that may cause anything listed above within the next 3-6 months.

I have been made aware of the National Institute of Communicable Diseases (NCID) guidelines that under level 3 and below pandemic lockdown elective procedures are allowed. Dental visits should still ideally be limited to the treatment of pain, infection, conditions that significantly inhibit normal operation of teeth and mouth, and issues that may cause anything listed above within the next 3-6 months.

I confirm I am seeking treatment for a condition that meets these criteria.

Information regarding my health*

I confirm that I am not presenting any of the following symptoms of COVID-19 listed below:

• Fever
• Shortness of Breath
• Dry Cough
• Runny Nose
• Sore Throat
• Loss of taste and or smell
• Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue

Additional Information

Are you in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Yes
No

Is your age over 65?

Yes
No

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

Yes
No

Details

Additional meassures taken by Dr Christa Engelbrecht Dental - IT IS IMPERATIVE THAT YOU FAMILIARISE YOURSELF WITH OUR PROCEDURES BEFORE YOUR VISIT*

I acknowledge and understand the additional measures taken at Dr Christa Engelbrecht Dental to prevent the spread of COVID-19.

Please also note the following important changes when visiting us. These are additional measures over and above the usual stringent cross infection measures our patients are used too:

We are following the Guidelines as set out by the South African Dental Association, SADA DENTAL CLINICAL PROTOCOL IN RESPONSE TO COVID-19 PANDEMIC 2020 (10 May 2020), and have implemented all additional cross-infection requirements. Additional measures have also been implemented to protect our patients, ourselves, and our families.

We are now once again using our reception area. Please arrive on time for your appointment.

Patients are requested to come on their own. Children must be accompanied by no more than one adult.

We request that you have as little as possible with you.

We are now once again taking on-site payments, but you can still pay via EFT within 24 hours of receiving your emailed statement.

Once in the surgery, you will be asked to remove your mask and rinse your mouth with a betadine mouthwash for 1 minute. Please let us know if you have an iodine allergy. This has been proven to significantly reduce the intra-oral bacterial and viral load.

Alcohol Hand sanitisers are available throughout the practice.

Please use this space if you have any questions regarding visiting us during Level 3 Lockdown.

Signature

Date

COVID-19 Pandemic Dental Treatment Patient Consent Form

Dr. Christa Engelbrecht Dental