J-7, Navarathna Colony, PV Rajamannar Salai, KK Nagar West,

Chennai – 600078
Ph no: 98849 82024, 98414 89660

Special Informed Consent for Dental Surgery treatment during the period of the COVID 19 epidemic

Date:

I, _, C/o, ( ),

aged years, residing at

telephone no: , declare that I have not been diagnosed with the Novel Corona Virus
Influenza / have fully recovered from the infection and am not isolated or quarantined for the same by any
health authority at this time.

I do not have any symptoms of fever, cough or any other signs indicative of Corona virus infection or any
similar condition.

Any comorbid illness, If present:

Diabetes mellitus Kidney illness

Hypertension Any drug allergies, please specify ………………………………

Any recent surgeries ……………………………………………………………………………………

Cardiac illness

My treating dentist has fully explained to me

1. That the treating dental surgeon or staff in this facility has not been tested and diagnosed with
Corona virus through standard testing nor do they have any symptoms suggestive of the infection to
the best of his/her knowledge.

2. That the clinic is currently undertaking only emergency treatment for dental pain, trauma, infection
or any condition deemed to be absolutely essential. Any condition requiring advanced emergency
treatment will be admitted to a hospital or referred for management of the same to a specialist.
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3. That aerosol producing procedures (using water spray) will not be routinely used and if needed as
an emergency, will be done with full protection for the patient, doctor and staff in a limited manner.

4. That the premises and treatment area has been sanitized to the best of our capabilities to prevent
infection to any person in the clinic.

5. That there should be complete compliance to all precautions and instructions outlined by the
doctors/ staff to every patient for the safety of all concerned.

6. That certain dental procedures are modified to prevent accidental spread of infection and may not
be in line with treatment at ordinary times.

7. That the following treatment has been recommended as a minimal invasive emergency procedure
and modified as follows if it carries a risk to the operator/ patient/ community.

8. This document absolves the clinic, staff and all its support staff of all liabilities, in case any patient
has any inadvertent complication including but not limited to acquiring any infection from viruses
subsequent to their treatment in this facility.

DETAILS OF PROPOSED TREATMENT:

I have read the contents of the above document and I fully agree and consent to the treatment.

Patient’s Signature Doctor’s Signature

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