COVID-19 Consent Form

Below is a list of our precautions to ensure safety and health of staff and patients:

1. We are employing passive and active screening of all patients prior to their appointments. Patients are pre-screened over the phone to ensure the absence of COVID symptoms and then again upon arrival.  Our front door is locked and only patients with an appointment are permitted to enter.  Only children can be accompanied by one caregiver.  An infrared thermometer temperature check is taken on all patients upon entry.


2. Patients are asked to wear a mask when coming to the clinic.


3. Hand sanitizer is readily available, and patients are asked to sanitize hands upon entry into the clinic.


4. All surfaces are routinely wiped down with a disinfectant. 


5. All magazines and toys have been removed from the reception area.


6. We will attempt to stagger the appointment times to minimize overlapping of patients in the office and patients will be asked to social distance.


7. A plexiglass barrier was installed at the reception.


8. A pre rinse of Hydrogen Peroxide has been introduced for all patients.


9. HEPA air filtration units have been installed in each operatory.


10. Personal protective equipment is available if deemed necessary such as fitted N95 masks, goggles, face shields, caps and gowns.


11. Longer appointment times are booked and spacing between patients has been increased to provide extra time for the completion of work in the safest and most comprehensive way possible and to better allow for social distancing.  This will limit your appointment time booking options.  Thank you for understanding. 

* Patient Name:

* I understand that dental procedures create water spray which is one way that the Novel Coronavirus can spread.

Initials Required Above

* 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 a risk of contracting the Novel Coronavirus by being in a dental office. I also understand that my dentist will attempt to social distance patients by asking them to wait outside the clinic prior to their appointment and providing extended treatment times, has purchased HEPA air filtration units in order to increase the air changes per hour, will close the doors of the operatories during aerosol generating procedures, uses high volume suction and rubber dams where possible in order to decrease this risk.

Initials Required Above

Screening for symptoms of COVID-19

Identified by Ontario Public Health that are new or worsened if associated with allergies or other chronic conditions:

* Do you have a fever?

Yes

No

* What is your Temperature in Degrees Celsius?

* Do you have a new cough or worsening chronic cough?

Yes

No

* Do you have a sore throat?

Yes

No

* Do you have shortness of breath?

Yes

No

* Do you have difficulty breathing or swallowing?

Yes

No

* Do you have flu-like symptoms, chills, muscle aches?

Yes

No

* Do you have a runny nose without another known cause?

Yes

No

* Do you have decreased or loss of smell or taste?

Yes

No

* Do you have nausea/vomiting, diarrhea, abdominal pain?

Yes

No

* Do you have pink eye?

Yes

No

* I am not in a high risk category including: diabetes, cardiovascular disease, hypertension, lung diseases including moderate to severe asthma, being immunocompromised, having active malignancy or over age 70

I confirm

I do not confirm

I fall into the following high risk category and my dentist and I have discussed the risks, and I agree to proceed with treatment.

Initials Required Above

If you are 70 or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?

No I am not

Yes I am

What symptoms are you experiencing?

* I confirm that I am not currently positive for COVID-19.

Initials Required Above.

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

Initials Required Above.

* I confirm that I have not been in contact with any confirmed COVID-19 positive patients or persons self-isolating because of a determined risk for COVID-19 within the last two weeks.

Initials Required Above.

* I understand that Ontario Public Health has asked individuals to maintain physical distancing of at least 2 meters and it is not possible to maintain this distance and receive dental treatment.

Initials Required Above.

* I verify that I have not been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by Ontario Public Health, the Communicable Disease Control or any other governmental health agency.

Initials Required Above.

* I verify that information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have a dental treatment during the COVID-19 pandemic.

Initials Required Above.