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New Patient Forms
Our Team
Our Services
Cosmetic Dentistry
Crowns
Dental Anxiety
Dental Emergencies
Dental Fillings
Dental Implants
Dental Sealants
Dentures
Kids Dentistry
Laser Dentistry
Mouthguards & Sportsguards
Orthodontics
Root Canals
Teeth Whitening
Tooth Extractions
Veneers
X-Rays
Request Appointment
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Online Patient Form
covidconsent
COVID-19 Consent Form
Patient Acknowledgement: COVID-19 Pandemic Emergency Dental Risk
Please read the patient acknowledgement below, use the checkboxes to attest that you have understood the paragraph and sign in the area indicated.
Please ensure you receive a confirmation that your form was submitted, if not, please go back and answer ALL the questions.
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.
*
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.
I have read, understood and agree to this statement.
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.
*
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.
I have read, understood and agree to this statement.
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.
*
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.
I have read, understood and agree to this statement.
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.
*
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.
I have read, understood and agree to this statement.
I confirm that I do NOT have any TWO OR MORE or the following symptoms of COVID-19: (i) fever, (ii) new or worsening cough, (iii) sore throat, (iv) runny nose or (v) headache.
*
I confirm that I do NOT have any TWO OR MORE or the following symptoms of COVID-19: (i) fever, (ii) new
or worsening cough, (iii) sore throat, (iv) runny nose or (v) headache.
I attest to the above information to be truthful.
If I received COVID-19 test results in the past three (3) months, the last results I received were negative.
*
If I received COVID-19 test results in the past three (3) months, the last results I received were negative.
I have NOT received a COVID-19 test OR the results were negative.
If applicable Approximate date of negative test:
If applicable
Approximate date of negative test:
I confirm that I am not waiting for the results of a test for COVID-19.
*
I confirm that I am not waiting for the results of a test for COVID-19.
I attest to the above information to be truthful.
I confirm that this is not currently a period during which public health authorities required I self-isolate for 14 days.
*
I confirm that this is not currently a period during which public health authorities required I self-isolate
for 14 days.
I attest to the above information to be truthful.
Name
*
First
Last
Signature
*
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.
Date
*
DD slash MM slash YYYY
Did you complete the form?
Please ensure you have completed the entire form, and ensure after hitting submit you receive a confirmation that it was sent. If you do NOT receive the confirmation, go back, and answer the questions you missed. Thank you!
Yes (Select to be able to submit the form)