COVID-19 Consent Form

COVID-19 Pandemic
Dental Treatment Consent Form

Even after following protocols set by the American Dental Association and the Georgia Dental Association, it is still possible to contract COVID-19 while at a dental office. We are following all guidelines to minimize the risk of transmission.

*I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic. I understand that the COVID-19 virus has a long incubation period during which carriers of this virus may not show symptoms and may still be highly contagious.

*I confirm that I am not presenting any of these COVID-19 symptoms:

  • Fever
  • Shortness of breath
  • Dry cough
  • Runny nose
  • Sore throat

*I confirm that I have not been in contact with a person who has been diagnosed with COVID19 within the past 14 days.

*I understand that – due to the frequency of visits of other dental patients, the characteristics of the COVID-19 virus, and the characteristics of dental procedures – I have an elevated risk of contracting the COVID-19 virus simply by being in a dental office.

*I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. The CDC recommends social distancing of at least six feet for a period of 14 days to anyone who has recently traveled and this is not possible with dentistry.

*Keeping staff & clients safe is our priority. By adding & upgrading materials & equipment (PPE) please be advised that there will be a $15 PPE fee that the American Dental Association is currently working to get covered under insurance.

*Printed Name (Patient)

*Date of Birth (Patient)

*Signature (Patient/Legal Guardian)


We look forward to serving you,

The team at kksmiles.


Please fill-up the form below as this is required on every visit to our clinic.

*First Name

*Last Name

*Date of Birth

*Do you/they have a fever or have you/they felt hot or feverish recently (14-21 days)?

*Are you/they having shortness of breath or other difficulties breathing?

*Do you/they have a cough?

*Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

*Have you/they experienced a recent loss of taste or smell?

*Are you/they in contact with any confirmed COVID-19 positive patients?

*Is your/their age over 60?

*Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

*Have you been tested positive to COVID-19?

*Have you/they traveled in the past 14 days outside your state of residence?

Patients who are well but who have a sick family member at home with COVID-19 should consider postponing/rescheduling elective treatment. Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with dental treatment.

*Signature of Patient or Legal Guardian