I confirm that I am not presenting any of the following symptoms of COVID-19 listed below:

• FEVER (feeling hot to touch, a temperature of 100 degrees Fahrenheit or higher)
• CHILLS
• COUGH that's new or worsening (continuous, more than usual)
• BARKING COUGH, making a whistling noise when breathing ('CROUP')
• SHORTNESS OF BREATH (out of breath, unable to breathe deeply)
• SORE THROAT
• DIFFICULTY SWALLOWING
• RUNNY NOSE (not related to seasonal allergies or other know causes or conditions)
• NASAL CONGESTION (not related to seasonal allergies or other known causes or conditions)
• LOSS OF SENSE OF SMELL
• PINK EYE (conjunctivitis)
• HEADACHE that's unusual or long-lasting
• DIGESTIVE ISSUES (nausea/vomiting, diarrhea, stomach pain)
• MUSCLE ACHES
• EXTREME TIREDNESS THAT IS UNUSUAL (fatigue, lack of energy)
• FALLING DOWN MORE THAN USUAL
• FOR YOUNG CHILDREN & INFANTS: Sluggishness or lack of appetite

I verify that I have not traveled outside of Canada in the past 14 days and have been advised to quarantine per the federal quarantine requirements.

I, knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.

Thank you for doing your part in keeping everyone safe. Please note the following:

• wear a MASK when entering the dental office
• SANITIZE your hands immediately upon arrival
• maintain Social Distancing from other patients
• have your Temperature taken by our team members
• not have any Accompaniment except small child/caregivers/translators