Patient Screening & Consent Form

Please complete and submit this form at least 48 hours prior to your scheduled appointment.

Patient Name *

Email Address *

Date of Birth *

Month

Day

Year

COVID-19 Pandemic Emergency Dental Risk

By submitting this consent form you are indicating that you have read, understand, and confirm the statements and terms as described.

I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. 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. For this reason, it is recommended to stay home and avoid close contact with other people when at all possible *

I confirm

I understand the federal and provincial governments have asked individuals to maintain social distancing of a least 2 metres (6 feet) and I recognize it is not possible to maintain this distance while receiving dental treatment *

I confirm

I understand that it is possible that oral surgery/dental procedures can create water and/or blood spray, which may be 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. *

I confirm

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

I confirm

I confirm that I do NOT have any TWO OR MORE or the following symptoms of COVID-19: fever, new or worsening cough, sore throat, runny nose or headache *

I confirm

I confirm that I have not tested positive for COVID-19 in the last 5 days. *

I confirm

I confirm that I am not waiting for the results of a test for COVID-19. *

I confirm

I confirm that this is not currently a period where I am required to self-isolate. *

I confirm

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

I confirm

Date *

Month

Day

Year

Patient Screening & Consent Form

COVID-19 Pandemic Emergency Dental Risk

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