COVID-19 - URGENT DENTAL TREATMENT PATIENT DECLARATION & CONSENT FORM (DCF)

I,

ID Number

knowingly and willingly consent to have urgent dental treatment during the COVID-19 pandemic.

  • I understand that the nature of dental procedures poses an elevated risk of contracting the virus and I absolve the Bluedent Speciality Dental Clinic of any liability in this regard.

  • I understand that the dental treatment provided will be limited to the treatment of acute pain, infection or conditions that significantly inhibit normal function of my teeth and mouth or to prevent potential progression to a serious complication.

  • I confirm that I do not have any of the following symptoms of COVID-19 such as fever, shortness of breath, dry cough, runny nose or sore throat.

  • I confirm I have not been in contact with any person with symptoms of COVID-19 in the past 14 days.

  • I verify that I have not traveled outside nor arrived in the Sultanate of Oman in the past 14 days.

  • I understand that physical distancing of at least 6 feet is not possible with dentistry.

  • I acknowledge that to the best of my knowledge all the information I have provided in the Patient Screening Form is correct.

  • I agree to inform this dental healthcare facility if I develop any symptoms suggestive or test positive for COVID-19 within the next 14 days.

  • By ticking this box, inserting my name and ID number below, I accept the content of this Consent Form.

Thanks for submitting!

PATIENT TRIAGE SCREENING FORM FOR COVID-19