Please read the patient acknowledgement below, and initial or sign in all areas indicated.
I understand the novel coronavirus causes the disease known as COVID-19 and that it is
currently a pandemic. I understand that 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, I understand that the federal and provincial authorities have recommended
that Ontarians stay home and avoid close contact with other people when at all possible.
(initial)
I understand the federal and provincial authorities have asked individuals to maintain social
distancing of a least two (2) meters (six (6) feet) and I recognize it is not possible to maintain
this distance while receiving dental treatment.
(initial)
I understand that oral surgery/dental procedures can create water and/or blood spray, which
is one way that the novel coronavirus can spread. I understand that the ultra-fine nature of
the spray can linger in the air for minutes to sometimes hours, which can transmit the novel
coronavirus.
(initial)
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
the novel coronavirus simply by being in the dental office.
(initial)
I agree to complete a COVID-19 screening questionnaire as required by the Ministry of Health.
(initial)
If I received COVID-19 test results in the past three (3) months, the last results I received were
negative.
(initial)
If applicable, approximate date of test:
(initial)
I confirm that I am not waiting for the results of a test for COVID-19.
(initial)
I confirm that this is not currently a period during which public health authorities required I
self-isolate for 14 days.
(initial)
I confirm that I do NOT have andy TWO OR MORE of the following symptoms of COVID-19: fever, new or worsening cough, sore throat, runny nose or headache
(initial)
I verify the information I have provided on this form is truthful and complete. I knowingly
and willingly consent to have emergency surgical/dental treatment completed during the
COVID-19 pandemic.
NAME OF PATIENT, PARENT, or GUARDIAN
Email
Date
Phone No.
