I, First Name: Last Name: , consent to receive treatment from Peter A. Russo, DDS INC. during the COVID-19 outbreak. I understand that I need to wear a mask as directed in office. I will maintain a 6ft social distance from other patients. I understand that due to the unknowns of this virus, the number of other patients that have been in the practice and the nature of the procedures performed here, that I have an increased risk of contracting the virus by being in the practice and by receiving treatment in the practice. I understand that dental procedures have the potential to include aerosol-generating procedures as well as anticipated splashes and sprays, which are some of the ways that COVID-19 can be spread. I understand and take responsibility for the risks associated with receiving dental treatment during the COVID-19 pandemic.
I agree to notify the dental practice if within 14 days I become ill with COVID-19 symptoms or test positive for COVID-19. I understand the dental practice has a legal and ethical obligation to inform me if a staff person I had contact with tested positive for COVID-19 within 14 days.