COVID-19 Treatment Consent Form

Please answer the questions and fill out the form below.

Click here to download and print the consent form.

Do you have fever or have you felt hot or feverish recently (14-21 days)?	YesNo
Are you having shortness or breath or other difficulties breathing?	YesNo
Do you have a cough?	YesNo
Do you have flu-like symptoms, such as gastro-intestinal upset, headache or fatigue?	YesNo
Have you experienced recent loss of taste or smell?	YesNo
Are you in contact with any confirmed COVID-19 positive patients? (Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment).	YesNo
Do you have heart disease, lung disease, kidney disease, diabetes, or any other auto-immune disorders?	YesNo
Have you traveled in the past 14 days to any regions affected by COVID-19?	YesNo

The above information is true to the best of my knowledge.

DISCLOSURE:
You are receiving dental care during the events of COVID-19 National Emergency. Please be advised that there may be risks in being in the proximity of dentists, staﬀ, and other patients. We are taking precautions to limit the spread of disease, yet there is still a possibility of transmission.

I would like to have dental treatment by TNT Dental Care team. I understand my risks in the disclosure above.

Please fill and sign:

Date

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Call: 617-923-0088

230 Main Street
Watertown, MA 02472

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Working Hours

Mon: 8:30 am - 5:00 pm
Tue: 7:30 am - 4:00 pm
Wed: By Appointment Only
Thu: 8:30 am - 6:00 pm
Fri: By Appointment Only
Sat: By Appointment Only
Sun: Closed

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