You are receiving dental care during the pandemic events of COVID-19 National Emergency. Please be advised that there may be increased risk of exposure from doctors, staff, other patients, and the treatment facility. We are taking precautions to limit the spread of this disease, but there is still a possibility of transmission.

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I understand that 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 who has it and who does not, given the current limits on virus testing. Dental procedures create water spray which is how the disease is spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the COVID-19 virus.

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I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic. I do hereby acknowledge the health risks of the COVID-19 virus during this National Emergency and I willfully request and authorize the doctors and staff at Fair Lakes Family and Cosmetic Dentistry to perform any necessary dental and/or orthodontic services. I will be responsible for any charges incurred for my treatment.