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COVID-19 Safety

Safety Procedures & Screening Form
 416-444-9045     1200 Lawrence Ave East, Suite 101

Treatment Consent Form

When you arrive for your appointment, we will take your temperature and ask you to:

  • Sanitize your hands
  • Answer these questions again
  • Complete the following Consent form
Patient's Name:

E-mail:

I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

INITIAL HERE

I understand that due to the frequency of visits of other dental 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 a dental office.

INITIAL HERE

I confirm that I am not presenting ANY of the following symptoms of COVID-19 identified by Ontario Health Services:

INITIAL HERE


  • Fever > 38°C
  • Cough (New or Worsening)
  • Shortness of Breath
  • Difficulty Breathing
  • Sore Throat
  • Difficulty Swallowing
  • Decrease or loss of sense of taste or smell
  • Chills
  • Headaches
  • Unexplained fatigue / Malaise / Muscle Aches (myalgias)
  • Pink eye (conjunctivitis)
  • Runny nose / nasal congestion without other known cause
  • Nausea/vomiting, diarrhea, abdominal cramps (of unknown origin)

I confirm that I am not currently positive for the novel coronavirus.

INITIAL HERE

I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus or in self-isolation.

INITIAL HERE

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.

INITIAL HERE

I understand that federal and provincial authorities have asked individuals to maintain social distancing of at least 2 meters (6 feet) and it is not possible to maintain this distance and receive dental treatments.

INITIAL HERE

Signature:

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