COVID Dental Treatment Consent Form

COVID-19 Patient Treatment Consent Form

Due to the COVID-19 Pandemic we have instituted an additional dental treatment consent form. Please submit the form prior to arrival.

PLEASE BRING YOUR OWN MASK OR FACE COVERING. YOU WILL BE ASKED TO USE OUR HAND SANITIZER UPON ENTERING AND LEAVING THE OFFICE.

Printable COVID Form

Patient's Name:

E-mail:

I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

Click to Initial

I understand that dental procedures create water spray which is one way that the novel coronavirus can spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus.

Click to Initial

I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Public Health Services:

  • Fever > 38°C
    Click to Initial
  • Cough (new or worsening chronic)
    Click to Initial
  • Sore Throat
    Click to Initial
  • Shortness of Breath
    Click to Initial
  • Difficulty Breathing
    Click to Initial
  • Flu-like Symptoms
    Click to Initial
  • Runny Nose
    Click to Initial
  • Conjunctivitis (Pink Eye)
    Click to Initial
  • Decrease or loss of sense of taste or smell
    Click to Initial
  • Chills
    Click to Initial
  • Headaches
    Click to Initial
  • Unexplained Fatigue / malaise / muscle aches
    Click to Initial
  • Nausea/vomiting, diarrhea,abdominal pain
    Click to Initial
  • Difficulty swallowing
    Click to Initial

OR

I confirm that I am not currently positive for the novel coronavirus.

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I confirm that I have not had close contact with anyone with a confirmed case of COVID-19 without wearing the appropriate PPE.

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I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus.

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I verify that I have not returned to Ontario from any country outside of Canada whether by car, air, bus or train in the past 14 days.

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I understand that any travel from any country outside of Canada, including travel by car, air, bus or train, significantly increases my risk of contracting and transmitting the novel coronavirus. Ontario Health Services require self-isolation for 14 days from the date a person has returned to Canada.

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I understand that Public Health has asked individuals to maintain social distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive dental treatment.

Click to Initial

I verify that I have not been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by Public Health, the Communicable Disease Control or any other governmental health agency.

Click to Initial

Signature:

Printed Name:

COVID-19 SAFETY UPDATE

Our new COVID-19 Safety Procedures and our Patient Screening Form can be found here: