COVID-19 Dental Treatment Consent Form

Patient Name:

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. I understand that dental procedures create water and/or blood spray which is one way that the novel coronavirus can spread 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.

I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Ontario Public Health Services: (Please initial only if you have symptoms)

Fever > 38°C

Chills

Headaches

New cough or worsening chronic cough

Sore throat or difficulty swallowing

New or worsening shortness of breath

Difficulty Breathing

Flu-like symptoms

Runny Nose/nasal congestion w/out other known cause

Decrease or loss of sense of smell or taste.

Muscle aches

Unexplained fatigue/malaise

Nausea/vomiting/diarrhea/abdominal pain

Pink eye (conjuncitivitis)

I confirm I know that there are categories of people who are considered to be high risk. I understand the high risk category factors are being 65 years of age or older, heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder

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

I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus.

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 Services, or any other governmental health agency.

I verify the information I have provided on this form is truthful and accurate.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient

Date

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