COVID-19 Pandemic Dental Treatment Consent Form

    Patient name: *

    I confirm that in last five days (if fully vaccinated) or last 10 days ( if not vaccinated or immunocompromised). I am not presenting any of the following symptoms of COVID 19 Identified by Ontario Health Services:

    • Fever > 38°C * (Initial)

    • New cough * (Initial)

    • Sore throat or painful swallowing * (Initial)

    • New or worsening shortness of breath * (Initial)

    • Difficulty Breathing * (Initial)

    • Flu-like symptoms * (Initial)

    • Runny Nose * (Initial)

    • Loss of taste and smell * (Initial)

    • Nausea, vomiting or diarrhea * (Initial)

    I confirm that I am not currently positive for the novel coronavirus and not waiting for the results of a laboratory test for the novel coronavirus. * (Initial)

    I 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.
    * (Initial)

    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 Health, the Communicable Disease Control or any other governmental health agency. * (Initial)

    I verify the information I have provided on this form is truthful and accurate. * (Initial)

    Printed Name *      Date *