Updated: 3/8/2021 MEK
PATIENT REQUEST FOR TREATMENT
INFORMED CONSENT
I acknowledge and understand that there is an increased risk that COVID19 can be transmitted in any place of public
accommodation, including a dental office, and I have been informed that my dentist desires to protect the safety of the
dental office and the patients, staff and other individuals who enter the premises.
Accordingly, as a precondition to rendering treatment to myself as the patient, or my child as the patient, I have
confirmed that:
• I/we have no symptoms associated with COVID19, including fever, shortness of breath, dry cough, running nose
or sore throat.
• I/we have followed the below NJ DOH recommendations (update: 3/8/2021) for individuals returning from travel
from any U.S. state or territory beyond the immediate region of New York, Connecticut, Pennsylvania, and
Delaware:
After returning to NJ, the state recommends getting tested within 3-5 days of your return, and the following
quarantine times based on the results of your test: If travelers test negative, they should still quarantine for a
full 7 days after travel. If testing is not available (or if the results are delayed), travelers should quarantine for 10
days after travel. If travelers have tested positive in the past 3 months, they do not need to quarantine or get
tested again during that three-month period as long as they do not develop new symptoms. If travelers test
positive, they should follow the DOH guidelines for quarantining.
• I /we have not within the past 10 days, been in close proximity (less than 6 feet) at a gathering of 25 or more
persons, or had close contact with a person who has confirmed positive for COVID19 or is presumptive positive
for COVID19.
I hereby consent to the treatment proposed by the dentist for myself as the patient, or for my child as the patient.
Printed Name: ________________________________________
Signature: ________________________________________
Date: ________________________________________
