Patient Acknowledgement of COVID-19 Pandemic Risk
This form is adapted from Dental Association of PEI COVID-19 Pandemic Emergency Dental Risk Acknowledge by Patient.
Please read this form and sign where indicated.
1. I understand there is currently a health pandemic associated with COVID-19 and the novel coronavirus.
2. I understand public health authorities have recommended maintaining social distancing of a least 2 meters(6 feet) and it is not possible to maintain this distance while receiving dental treatment.
3. I understand that oral surgery/dental procedures can create water and/or blood spray, and that there may be an elevated risk of contracting and spreading the novel coronavirus in a dental office.
4. I confirm that I do not have any two or more of the following symptoms of COVID-19: fever, new or worsening cough, sore throat, runny nose, or headache, and that this is not currently a period where I am required to self-isolate for 14 days.
5. I hereby consent to have dental treatment completed during the COVID-19 pandemic.