Covid-19 Pandemic Dental Treatment Consent form

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Although our clinic has always followed a very high level of infection control procedures set out by Ontario Public Health, RCDSO and CDHA we have created further safety steps to help prevent the spread of COVID-19. Our top priority is to keep all our staff and patients healthy, safe, and educated. Please read the following mandatory consent form and submit it prior to your next visit.

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 can confirm that I am not presenting any of the following symptoms of COVID-19 identified by Ontario public health services:

  • Fever > 38C
  • New cough or worsening chronic cough
  • Sore throat or painful swallowing
  • New or worsening shortness of breath
  • Difficulty breathing
  • Flu-like symptoms
  • Runny nose

I confirm I know that there are categories of people who are 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.

OR

I fall into the high-risk categories and my dentist and I have discussed the risks, and I have agreed to proceed with treatment.

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

I confirm that I am not currently waiting for results of a laboratory test for the novel coronavirusI verify that I have not returned to Ontario from any country outside of Canada whether by car, air, bus, or train in the past 14 days

I understand that any travel from any country outside of Canada, including travel by car, air, bus, or train, significantly increases my risk of contracting and transmitting the novel Coronavirus.
Ontario Public health services requires self-isolation for 14 days from the date a person has returned to Canada.

I understand that Ontario Public Health Services has asked individuals to maintain physical distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive dental treatment.

I verify that I have not been in contact with someone who has tested positive for the novel coronavirus or been asked to self-isolate by Ontario Public health, or any other governmental health agency.

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

_____________________________________________ SIGN HERE
Signature of patient