• Lake Country Dental
    Dr. Ray Snider DDS
    and Associates

  • COVID-19 Pandemic
    Dental Treatment Consent Form

  • Even after following protocols set by the American Dental Association and our state's dental association, it is still possible to contact COVID-19 while at a dental office. We are following all guidelines to minimize the risk of transmission.
    • I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic. I understand that the COVID-19 virus has a long incubation period during which the carriers of this virus may not show symptoms and may still highly be contagious.
    • I understand that - due to the frequency of visits of other dental patients, the characteristics of the COVID-19 virus, and the chracteristics of dental procedures - I have an elevated risk of contracting the COVID-19 virus simply by being in a dental office.
    • I confirm that I am not presenting any of these COVID-19 symptoms
      • Fever
      • Shortness of Breath
      • Dry Cough
      • Runny Nose
      • Sore Throat
    • I confirm that I have not beein in contact with a person who has been diagnosed with COVID-19 within the past 14 days.
    • I understand that air travel significantly increases my risk of contracting the COVID-19 virus. And the CDC recommends social distancing of at least six feet for a period of 14 days to anyone who has recently traveled, and this is not possible with dentistry.
    • I verify that I have not traveled outside the United States in the past 14 days.
    • I verify that I have not traveled domestically within the United States by commercial airline, bus, or train within the past 14 days.