Broadlands Dental Surgery - Appointment Form
Consent
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 per patient/person.Dental procedures take place with the patient in very close proximity to the service provider. This potentially exposes the patient and the operator to saliva and to coolant water spray, which may spread the disease. The ultra-fine nature of the spray and droplets may linger in the air for minutes to sometimes hours, which can transmit the COVID-19 virus. *
First Name *
Last Name *
Email *
Contact Number *
I knowingly and willingly consent for myself or for the following minor under my care to have elective dental or emergency dental treatment completed during the COVID-19 pandemic. *
I confirm that I am not presenting any of the following symptoms of COVID-19 listed below: *
Yes
No
Fever
Shortness of Breath
Dry Cough
Runny Nose
Sore Throat
I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. The NICD recommends social distancing of at least 1 meter for a period of 14 days to anyone who has, and this is not possible with dentistry. *
I verify that I have not travelled outside Zimbabwe in the past 14 days to countries that have been affected by COVID-19. *
I verify that I have not travelled domestically within Zimbabwe by commercial airline, bus, or train within the past 14 days. *
Guardian Signature *
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