| I, hereby declare consciously and voluntarily willing to undergo the dental care in the midst of an outbreak of Covid virus infection 19. I realize that the Covid 19 virus is very contagious and can be transmitted by someone who does not show any symptoms.Dental care procedures may cause water vapor that allows the Covid 19 virus to float in the air and be inhaled by people in the room. Therefore, I realize that: |
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The dentist's office is one of the high risk places for me to be infected with the Covid 19 virus |
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I have understood that during the Covid 19 virus outbreak, the authorities had issued recommendations to postpone all types of non-emergency dental care. Dental care that is still recommended to be done is limited to emergency measures to deal with pain, infection, and disorders that significantly inhibit the normal functioning of the teeth and mouth. |
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I declare that I am NOT EXPERIENCING the following symptoms of Covid 19 infection:
- Fever
- Shortness of breath - puffing
- Dry cough
- Runny nose
- Sore throat
- Impaired sense of taste
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To the best of my knowledge, I declare that I have never been in contact with a positive person infected with Covid 19, a symptom infected with Covid 19 virus, or a person who is being quarantined because of Covid 19. |
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The health authorities suggested at the time of this outbreak that we should keep a distance of at least 1-2 meters from other people to minimize the possibility of transmission. I understand that this is not possible during dentistry treatment. |
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I understand that air transportation greatly accelerates and expands the spread of the Covid 19. Virus. I declare that I have not traveled by plane or traveled outside the city on any transportation in the past 2 weeks. |