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STAFFORD, Staffordshire  ST18 0SN
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Consent to Dental Treatment during COVID-19


I am aware that the current COVID-19 pandemic brings a number of known risks and a number of unknown risks. I have chosen to seek dental treatment during the pandemic in the knowledge that much is still unknown about the virus.  


I understand the coronavirus that causes COVID-19 has a long incubation period during which time carriers of the virus may not show symptoms yet still be highly infectious. I also understand that some people may have the virus but may not ever have any symptoms. I therefore understand it is impossible to determine who has the virus and I understand that I must assume that anyone anywhere could be infected and infectious


I confirm that I am not currently suffering from any of the following symptoms of Covid-19 and I have not suffered from any of these symptoms in the last 7 days


  • Fever (a temperature of 37.8 degrees centigrade or above).
  • A new persistent dry cough.
  • Muscle pains.
  • Headache.
  • Shortness of breath and breathing difficulties.
  • Severe pneumonia.
  • Loss of taste and/or smell.
  • Extreme fatigue.
  • Runny nose.
  • Sore throat


I confirm that I have not been in close contact (within 2 metres) of anyone suffering with any of these symptoms in the last 14 days


I understand that receiving dental treatment means that the UK government’s instruction to maintain social distancing of at least 2 metres is not achievable during treatment


I understand that some people are considered to be at greater risk of serious illness or higher mortality if they contract COVID-19 and I understand that these are individuals who:


  • Have pre-existing medical conditions such as heart and circulatory disease.
  • Have high blood pressure.
  • Have diabetes.
  • Are very overweight.
  • Are male.
  • Are over 60 years of age.
  • Are from a black, Asian or minority ethnic (BAME) background.


I understand that Mr Peter Nadin will take every precaution to make sure my treatment is provided according to strict clinical protocols and hygiene procedures


I consent to the treatment being provided during the current phase of Covid-19.


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