Covid-19 Consent Form

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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.

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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.

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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.

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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.

Have you received Covid-19 test results in the past 3 months? *

Yes

No

Approximate date of test if results were negative: (If you tested positive, please contact us) *

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I confirm that I am not waiting for the results of a test for COVID-19.

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I confirm that this is not currently a period during which public health authorities required I self-isolate for 14 days.

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I agree to complete a COVID-19 screening questionnaire as required by the Ministry of Health.

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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.

Patient Name *

Signature *

Clear

Relationship to the Patient: *

Name if not the patient *

COVID-19 Pandemic Dental Risk

Emergency! If you are in need of urgent dental care we will try our best to see you immediately.

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