test page 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) Signature of Patient/Guardian (use mouse or finger to sign) Today's Date Please prove you are human by selecting the Heart.
