Patient Consent Form - Covid - wimbledon dental

Patient Consent Form for Examination & Treatment During COVID-19 Pandemic

Please fill-in this form and press SUBMIT at the end. Thank you.

I understand that I am opting for an elective form of dental treatment. Either Examination/ Treatments / procedures or surgery.

Yes No

2) I understand that the novel Coronavirus (COVID-19) has been declared a worldwide pandemic by WHO (World health organisation) and that COVID-19 is highly contagious and is spread by person to person contact, as a result social distancing is recommended. This is not entirely possible with my proposed treatment however; I am satisfied that safety measures are in place to minimise the risk as much as possible. I understand the risk of transmission of COVID-19 cannot be eliminated during the time I may spend in The Wimbledon Dental & Implant Centre.

Yes No

3) I am aware that COVID-19 has a long incubation period during which carriers of the virus may not show symptoms but be highly contagious. I am also aware that some people may have the virus but show no symptoms at all. I understand that in this instanced it is impossible to determine who has the virus and I must assume that anyone anywhere may be infected and could be contagious including members of staff at The Wimbledon Dental & Implant Centre.

Yes No

4) I understand that the management and clinical staff at The Wimbledon Dental & Implant Centre are closely monitoring the COVID-19 situation and have put reasonable preventive measures in placed aimed to reduce the risk of COVID-19. I understand there is a risk of becoming infected with COVID-19 by proceeding with treatment. I acknowledge and assume the risk of becoming infected with COVID-19 through this elective dental examination/ treatment/ procedure/ surgery and give my express permission to proceed.

Yes No

5) I am aware that COVID-19 can cause additional health risks, some of which may currently not be known at this time, in addition to the risks associated with the dental examination/ treatment/ procedure/ surgery itself.

Yes No

6) I have been offered the choice to defer my dental examination/ treatment/ procedure/ surgery to a later date and understand the potential risks, I would therefore like to proceed with my dental examination/ treatment/ procedure/ surgery.

Yes No

7) I am aware that emergency and urgent dental care is being provided in designated NHS urgent dental care centres (UDH). Some experts and governing bodies advise any dental treatments using a dental drill be carried out at one of these centres, however I confirm that I wish to be treated at The Wimbledon Dental & Implant Centre.

Yes No

8) I can confirm that I am not currently suffering from any of the following symptoms of COVID-19 and I have not suffered from any of these symptoms in the past 7 days:

Fever (a temperature of 37.5 degrees centigrade or above)
A new persistent dry cough
Muscle pains
Headaches
Shortness of breath or breathing difficulties
Severe Pneumonia
Loss of taste and/ or smell
Extreme fatigue
Runny nose
Sore throat

Yes No

9) I am aware that air travel significantly increases my risk of contracting and passing on the COVID-19 virus. I confirm that I have not travelled by air in the past 14 days.

Yes No

10) I confirm that I have not been in close contact (within 2 metres) of anyone suffering with any of the symptoms above in the past 14 days.

Yes No

11) I understand that receiving dental treatment means that the UK government’s instruction to maintain social distancing of 2 metres is not possible during treatment.

Yes No

12) I confirm that if I develop COVID-19 symptoms following the dental examination/ treatment/ procedure/ surgery, or a known contact of mine develops symptoms I will immediately inform The Wimbledon Dental & Implant Centre to enable appropriate measures to be put in place and contact tracing to commence.

Yes No

13) I am aware of the risks and benefits explained to me by Wimbledon Dental & Implant Centre and all my queries and questions have been.

Yes No

Consent

I hereby consent to the examinations and dental treatments provided during the current phase of COVID-19.*

Your First Name

Your Last Name

Date

Your Email Address