Patient First & Last Name



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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.

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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Did the person have close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days?

Yes

No


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Does the person have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?

Yes

No


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Is experiencing any of the following symptoms:
. Fever
. New onset of cough
. Worsening chronic cough
. Shortness of breath
. Difficulty breathing
. Sore throat
. Difficulty swallowing
. Chills
. Headaches

Yes

No


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Is experiencing any of the following:
. Decrease or loss of sense of taste or smell
. Unexplained fatigue/malaise/muscle aches (myalgias)
. Nausea/vomiting, diarrhea, abdominal pain
. Pink eye (conjunctivitis)
. Runny nose/nasal congestion

Yes

No


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If the person is 70 years of age or older, are they experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?

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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