Basking Ridge Pediatric Dentistry

Patient Request for Treatment
Representations and Consents


Responding to the public health hazard posed by Coronavirus disease 2019 (COVID-19), effective 5:00 pm on Friday, March 27, 2020, Governor Philip D. Murphy ordered and directed the suspension of all surgeries or invasive procedures performed on adults that can be delayed without undue risk to the current health of the patient as determined by the patient’s treating physician or dentist.


I acknowledge and understand that there is an increased risk that COVID-19 can be transmitted in any place of public accommodation, including a dental office, and I have been informed that my dentist desires to protect the safety of the dental office and the patients, staff and other individuals who come upon the premises.


Accordingly, as a precondition to rendering treatment, I have confirmed that I have no symptoms commonly associated with COVID-19, including:


-         Fever

-         Shortness of breath

-         Dry cough

-         Running nose

-         Sore throat


And that I have not, within the past 14 days, travelled by airplane, been in close proximity (less than 6 feet proximity) at a gathering of 10 or more persons, or have had close contact with a person who has confirmed positive or suspected to be positive for COVID-19.


I consent to the performance of the treatment proposed by Dr. Tina Nguyen.

Patient’s name
Guardian/Parent’s name
Signature
/ /
Date
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