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:



    Call: 617-923-0088

    230 Main Street
    Watertown, MA 02472

    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

    TNT Dental Care
    Service with a Smile!

    Feel  free to contact our office with any questions you may have. We look forward to making your visit a pleasurable experience!

    TNT Dental

    230 Main St, Watertown, MA 02472, USA

    Contact Us

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