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COVID Consent

Covatto Family Dentistry

3572 Brodhead Rd,
Monaca, PA 15061
(724) 728-7576

Patient Details( * mandatory to fill )
COVID 19 Emergency Dental Treatment Consent Form ( * mandatory to fill )


(patient name or if the patient is a minor, the patient's parent or legal guardian) knowingly and willingly consent, or, consent on behalf of

(insert minor patient's name, if applicable), knowingly and willingly consent to have emergency 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 currently impracticable to determine who may have COVID-19 and not yet be exhibiting symptoms.

I further understand that dental procedures create water spray which may be one source for transmission of the virus. The ultra-fine nature of the spray can linger in the air from several minutes to sometimes hours, which can cause transmittal of 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 contracting the virus simply by being in a dental office.
  •  I have been made aware of the CDC, ODA, and ADA guidelines that under the current pandemic of non-urgent dental care is not recommended. Dental visits should 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 that I am seeking treatment for a condition that meets these criteria.
  •  Furthermore, I confirm that I am not presenting any of the following symptoms of COVID19 listed below

* Shortness of breath
* Dry cough
* Sneezing/ Runny Nose
* Sore Throat
* Fatigue

  •  I understand that air travel significantly increases my risk of contracting and transmitting COVID-19 virus. I further understand the CDC recommends social distancing of at least 6 feet for a period of 14 days to anyone who has, and this is not possible with dentistry.
  •  * I verify I have not traveled outside the United States in the past 14 days to countries that have been affected by COVID-19.
  •  * I verify that I have not traveled domestically within the U.S. by commercial airline, buy, or train within the past 14 days.
  •  If, at any point in the next 14 days, I begin to exhibit symptoms of the COVID-19 virus, I will inform the practice immediately and will inform them of any testing results or quarantine orders I receive from a medical physician. I understand this continued communication with the practice is essential to help curb the spread of the virus and to allow the practice to provide informed consent to other patients and to otherwise take protective measures. I understand the practice will not share or disseminate any of my protected health information for any unlawful or prohibited purpose.
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