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Patient Name*

Email*

I understand the novel corona virus causes the disease known as COVID-19. I understand the novel corona virus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. I understand that dental procedures create water spray which is one way that the novel corona virus can spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the novel corona virus.
I understand
I understand that due to the frequency of visits of other dental patients, the characteristics of the novel corona virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the novel corona virus simply by being in a dental office.
I understand
I voluntarily consent to today's required COVID-19 assessment and I understand my right for refusal. If I choose to refuse today’s COVID-19 assessment, I understand my treatment would be postponed to a later date
I understand
I confirm that I am not presenting any of the following symptoms of COVOID-19 identified by ​Ontario ​Health Services:

Fever > 38°C I confirm
Cough I confirm
Sore Throat I confirm
Shortness of Breath I confirm
Flu-like symptoms I confirm
I confirm that I am not currently positive for the novel corona virus.
I confirm
I confirm that I am not waiting for the results of a laboratory test for the novel corona virus.
I confirm
I verify that I have not returned to ​Ontario ​from any country outside of Canada whether by car, air, bus or train in the past 14 days.
I confirm
I understand that any travel from any country outside of Canada, including travel by car, air, bus or train, significantly increases my risk of contracting and transmitting the novel corona virus. ​Ontario ​Health Services require self-isolation for 14 days from the date a person has returned to Canada.
I understand
I understand that ​Ontario ​Health Services 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.
I understand
I verify that I have not been identified as a contact of someone who has tested positive for novel corona virus or been asked to self-isolate by ​Ontario, ​Public Health, the Communicable Disease Control or any other governmental health agency.
I confirm
List of dental treatments
I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above listed emergency dental treatment completed during the COVID-19 pandemic.
I confirm
Parent/Guardian Name (if required)

Today's Date

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