COVID-19 Pandemic Dental Treatment Consent Form

I confirm that I do not have any of the following symptoms of COVID-19:

Fever over 38°C*

Yes
No

New or Worsening Cough*

Yes
No

Sore Throat*

Yes
No

New or Worsening Shortness of Breath*

Yes
No

New or Worsening Difficulty Breathing*

Yes
No

Flu-like Symptoms*

Yes
No

Are you currently positive for COVID-19?*

Yes
No

Have you been identified as a contact of someone who has tested positive for COVID-19?*

Yes
No

Are you waiting on testing due to being symptomatic or being identified as a contact for someone with COVID-19?*

Yes
No

Have you been outside of Canada in the last 14 days?*

Yes
No

Do you understand it is not possible to maintain physical distancing of at least 2 metres (6 feet) and receive dental treatment?*

Yes
No

Name*

First Last

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

Consent*

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.

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