Please read the screening questions, complete and sign the Consent Form prior to your appointment.  Thank you!

Pre-Screening Questions:

  1. Have you had close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days?
  2. Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?
  3. Do you have any of the following symptoms:
    • Fever
    • New onset of cough
    • Worsening chronic cough
    • Shortness of breath
    • Sore throat
    • Difficulty swallowing
    • Decrease or loss of sense of tatse or smell
    • Chills
    • Headaches
    • Unexplained fatigue/malaise/muscle aches (myalgias)
    • Nausea/vomiting, diarrhea, abdominal pain
    • Pink eye (conjunctivitis)
    • Runny nose/nasal congestion without other known cause
  4. Are you 70 years of age or older, experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?

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: