Re-opening announcement and COVID-19 safety protocol

We’re delighted that we can begin to re-open our practice from Monday 8th June after the government announcement. Please take a few minutes to read the following safety procedure we have prepared for keeping you and our staff safe

STEP 1: Before your appointment

Please print and read the Corona-virus consent form below carefully as you will need to sign it before we can start your treatment. We may also call you to conduct a pre-visit questionnaire to ensure you have no COVID-19 symptoms so we can treat you safely.

Read the Corona-virus consent Form

Admired Clinic

Dental Treatment Consent Form during the Covid-19 Pandemic

Patient name:

I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

I understand that dental procedures create a water spray which is one way that the novel coronavirus can spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus. (Initial) ______________ 

I understand that due to the frequency of visits of other dental patients, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have an elevated risk of contracting the novel coronavirus simply by being in a dental office. (Initial) ______________ 

I have been made aware of the UK national guidelines that under the current pandemic all non-emergency dental care is not allowed. Dental visits should be limited to emergency dental treatment which includes treatment of oral-facial trauma, significant infection, prolonged bleeding, pain which cannot be managed by over the counter medications, or management of known/high risk malignancy. (Initial) ______________ 

I confirm I am seeking treatment for a condition that meets these criteria. (Initial) ______________ 

I confirm that I am not presenting any of the following symptoms of COVID-19 identified by the NHS

  • Fever > 38°C  (Initial) ______________
  • Cough  (Initial) ______________
  • Sore Throat  (Initial) ______________
  • Shortness of Breath  (Initial) ______________
  • Difficulty Breathing  (Initial) ______________
  • Flu-like symptoms  (Initial) ______________
  • Runny Nose  (Initial) ______________
  • Loss or smell/taste  (Initial) ______________

I confirm that I am not in a high risk category, including: diabetes, cardiovascular disease, hypertension, lung diseases including moderate to severe asthma, being Immuno-compromised, having active malignancy, or over age 65. (Initial) ______________ 

OR

I fall into the following high risk category (__________________) and my dentist and I have discussed the risks, and I agree to proceed with treatment. (Initial) ______________ 

I confirm that I am not currently positive for the novel coronavirus. (Initial) ______________ 

I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus. (Initial) ______________ 

I verify that I have not returned to the UK from any country outside of the UK whether by car, air, ferry, bus or train in the past 14 days. (Initial) ______________ 

I understand that any travel from any country outside of the UK, including travel by car, air, bus or train, significantly increases my risk of contracting and transmitting the novel coronavirus. The UK NHS requires self-isolation for 14 days from the date a person has returned to the UK. (Initial) ______________ 

I understand that Public health England (PHE) has asked individuals to maintain physical distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive dental treatment. (Initial) ______________ 

I verify that I have not been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by the NHS, Public health England or any other governmental health agency. (Initial) ______________ 

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above listed dental treatment completed during the COVID-19 pandemic.

SIGNATURE OF PATIENT/GUARDIAN

Name

Date

 

STEP 2: Before you enter the practice

STEP 3: Inside the practice

STEP 4: After your appointment