I knowingly and willingly consent to having 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 impossible to determine who has it and who does not, given the current limits in virus testing in Bermuda. Dental procedures create water spray and aerosol 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. Please make every effort to answer the following questions honestly and truthfully as to keep you and our staff safe. Name* First Last I understand that due to the frequency of visits or 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.*(Please initial)I confirm that I am not presenting any of the following symptoms of COVIOD-19: Fever 100.4 degrees Fahrenheit or greater, Shortness of Breath, Dry Cough, Runny Nose, Sore Throat, Severe Headache*(Please initial)Have you or anyone you are in close contact with, been in contact with anybody that has been diagnosed or is being monitored for COVID-19 in the last 14 days?* Yes No Have you been tested for COVID-19?* Yes No When were you tested and what was the result?*Travelled via plane or ship in or out of Bermuda where positive COVID-19 cases have been identified in the last 14 days?* Yes No I fully understand the risks of having dental treatment performed during this pandemic and consent to dental treatment.Signature*