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Parent/Legal Guardian COVID-19 Risk Assessment and Consent

Select the appropriate answer for each question below


Travel outside of your home city:

Please list all locations the patient or others living in the patients home have visited within the last 30 days outside of the patient's home city:


By signing below, I acknowledge that there is increased risk for the spread of COVID-19 in a dental office, and that I consider this surgery a necessary procedure for my child. I understand the risk of me or my child being potentially exposed to COVID-19 while at the dental office, and I voluntarily assume that risk. I further understand that I have the right to reschedule the surgery for a later date if I have any concerns about the necessity of the surgery or risk for me or my child being potentially exposed to COVID-19.

I acknowledge that if my child presents the day of surgery with any symptoms of COVID-19, or has possible contact with someone who has COVID-19, surgery will be rescheduled for a later date.

I further acknowledge that I am the parent or legal guardian of the patient named above.

Electronic Signature
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