COVID-19 Pandemic
** WE ARE DOING IN OFFICE VERBAL ONLY NOW---YOU DON'T NEED TO DO THIS BELOW BUT SEE QUESTIONS WE WILL ASK**
Risk of Infection
The best available scientific evidence is that the Novel Corona Virus which causes COVID-19 is transmitted through droplets which can be caused by sneezing or coughing. This releases droplets into the air and/or onto surfaces. Certain medical and dental procedures can create a fine spray of water or particles in the air. The virus is known to be able to survive on surfaces for an extended period of time.At Dr. J. Belsito & Associates, we follow strict requirements for Infection Control and Prevention, including all enhanced directives issued by the Canadian Centre of Disease Control and related Federal and Provincial health authorities and more. Our Covid NEW OFFICE Sanitization & PROTOCOL can be found at www.belsitodental.com/forms. Our clinic and all treatment areas are sterilized, including after each dental procedure and patient visit. We are taking all necessary precautions to prevent transmission of the Novel Corona Virus, along with other viruses and bacteria. We are PPE compliant. Despite these efforts, given the unique attributes of the Novel Corona Virus, there may be an elevated risk of infection.
Have you had close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days?
Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?
Do you have any of the following symptoms:
• Fever • New onset of cough • Worsening chronic cough • 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) • Nausea/vomiting, diarrhea, abdominal pain • Pink eye (conjunctivitis) • Runny nose/nasal congestion without other known cause
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?
Are you fully vaccinated (2 doses) for Covid (more than 14 d ago)?
Acknowledgment and Consent
By signing this consent form, I verify the information I have provided on this form is truthful and complete. I knowingly and willingly consent to have dental treatment despite any possible elevated risks associated during this time of COVID-19 pandemic.
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