Tysons Aesthetic Dentistry

Dental Treatment Consent Form


I,  , consent to have dental treatment during the COVID-19 at this office. I have also been verbally informed of the risks.

  • I confirm that I am not presenting with any of the following symptoms of COVID-19 listed below:


Shortness of Breath  

Dry Cough        

Runny Nose 

Sore Throat      

Loss of taste or smell  



  • I affirm that I, as well as all household members, have not traveled outside of the country, or to any city outside of our own that is or has been considered a “hot spot” for
    COVID-19 infections within the last 14 days   (Initials)


I understand that this office screens all patients and staff for possible COVID-19 infection per the current guidelines. However, carriers of the virus may be completely asymptomatic and still be contagious. Some may never develop full blown symptoms. Presently, it is impossible to determine who is an asymptomatic carrier. This virus can be spread through droplets or contact. Additionally, certain Dental procedures create water mist (aerosol) which is one way the virus is spread. The aerosol and thus the virus can linger in the air for hours after certain dental procedures.

  • I understand that due to other dental patients visiting the office and due to the characteristics of the virus and dental procedures, I have an elevated risk of contracting the virus simply by being in a dental office. (Initial)
  • I have been made aware of the CDC and ADA guidelines that under the current pandemic all dental visits should be limited to the treatment of pain, infection or conditions that significantly impair normal function of teeth and mouth. (Initial)
  • I confirm I am seeking treatment for a condition that meets these criteria.  (Initial)
  • I understand the CDC recommends social distancing of at least 6 feet, and this is not possible when seeking dental care.  (Initial)

Leave this empty:

Signature arrow sign here

Signed by Dr. H. R. Makarita
Signed On: October 28, 2020

Signature Certificate
lock iconUnique Document ID: 974e9ef2db109b541e3cf81fd9b7438e811ee9fe
Timestamp Audit
October 23, 2020 11:05 pm GMTCOVID RELEASE FORM Uploaded by Dr. H. R. Makarita - IP