Patient Acknowledgement: COVID-19

Javascript is disabled

Javascript is disabled on your browser. Please enable it in order to use this form.

Page 1

Patient Acknowledgement:

COVID-19 Pandemic Emergency Dental Risk

Please read the patient acknowledgement below, and initial or sign in all areas indicated.

First Name*

First Name

Last Name *

Last Name

I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. 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. For this reason, it is recommended to stay home and avoid close contact with other people when at all possible.*

(initial)

I understand the federal and provincial governments have asked individuals to maintain social distancing of a least 2 metres (6 feet) and I recognize it is not possible to maintain this distance while receiving dental treatment.*

(initial)

I understand that oral surgery/dental procedures can create water and/or blood spray, which is one important way that the novel coronavirus can spread. The ultra-fine nature of the spray can linger in the air for minutes, which can transmit the novel coronavirus.*

(initial)

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 AND SPREADING the novel coronavirus simply by being in the dental office.*

(initial)

I confirm and accept that treatment provided may not necessarily be representative of the care that would be expected or provided under normal circumstances *

(initial)

I confirm that I do NOT have any of the following symptoms of COVID-19:

Fever, new or worsening cough, sore throat, runny nose (not related to seasonal allergies or other known causes or conditions) or headache. *

(initial)

I confirm that I have not tested positive for COVID-19.*

(initial)

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

(initial)

I confirm that this is not currently a period where I required to self-isolate for 14 days. *

(initial)

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have emergency surgical/dental treatment completed during the COVID-19 pandemic.

Date*