Patient First & Last Name



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I understand that 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.

Acknowledge


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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.

Acknowledge


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I understand that due to visits by other dental patients, the characteristics of the novel coronavirus, and that of dental procedures, that I have an elevated risk of contracting the novel coronavirus simply by being in a dental office.

Acknowledge


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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.

Acknowledge


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Do you have a fever or have felt hot or feverish anytime in the last two weeks?

Yes

No


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Do you have any of these symptoms:
. Dry cough?
. Shortness of breath?
. Difficulty breathing?
. Sore Throat?
. Runny nose?

Yes

No


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Have you experienced a recent loss of smell or taste?

Yes

No


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Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?

Yes

No


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Have you returned from travel outside of Canada in the last 14 days?

Yes

No


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Have you returned from travel within Canada from a location known affected with COVID-19?

Yes

No


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Are you over the age of 60?

Yes

No


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Do you have any of the following:
. Heart disease
. Lung disease
. Kidney disease
. Diabetes or any auto-immune disorder

Yes

No


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I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above listed dental treatment completed during the COVID-19 pandemic.

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