• Please read and sign:

    Please read the patient acknowledgment below and initial or sign in all areas indicated.
  • I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand that the novel coronavirus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. For this reason, I understand that the federal and provincial authorities have recommended that Ontarians stay home and avoid close contact with other people when at all possible.
  • I understand the federal and provincial authorities have asked individuals to maintain social distancing of at least two (2) meters (six (6) feet) and I recognize it is not possible to maintain this distance while receiving dental treatment.
  • I understand that oral surgery/dental procedures can create water and/or blood spray, which is one way that the novel coronavirus can spread. I understand that the ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus.
  • 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 the novel coronavirus simply by being in the dental office.
  • I agree to complete a COVID-19 screening questionnaire as required by the Ministry of Health.
  • If I received a COVID-19 test result in the past three (3) months, the last results I received were negative.
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  • I confirm that I am not waiting for the results of a test for COVID-19.
  • I confirm that this is not currently a period during which public health authorities require I self-isolate for 14 days.
  • I confirm that no one in my household has tested positive for COVID-19 in the past 30 days.
  • I verify that the information I have provided to this form is truthful and complete. I knowingly and willingly consent to have emergency surgical/dental treatment completed during the COVID-19 pandemic.