• COVID-19 Pandemic Patient Disclosure Form Prior to Appointments

  • Before receiving treatment, we would like to request the following information from you in accordance to safe guidelines from Public Health, our regulatory College, and the government. We appreciate your candor, time and understanding.

    (Please note: a weak or compromised immune system, including from diabetes, asthma, chronic obstructive pulmonary disease, or any other issues with your lungs, cancer treatment, radiation, chemotherapy or any prior or present medical conditions, may put you at a higher risk of contracting COVID-19. We may advise you to consider rescheduling your appointment to a later, safer date.)

    It is also very important that you disclose to this office any chance of having been exposed to COVID-19, or whether you have or are experiencing any signs or symptoms associated with the COVID-19 virus. It is for your health and safety, and that of our staff.

    You will also receive a copy of the completed form in your email.

    * Required.

  • Please check the “Yes” or “No” button to answer the following questions. Thank you.

  • I fully understand and acknowledge the above information and have provided to The Concourse Dental Centre any conditions about my health which may result in a compromised immune system.

    By clicking on the agree button and submitting this form, I acknowledge that my answers above are true and accurate.

  • Should be Empty: