Concourse Dental - Covid-19 Consent Form

COVID-19 Consent Form

If you agree to the statements below, please confirm by checking the buttons.

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

* Required.

Select a Date *

Name *

Email *

1. I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand that the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. For this reason, I understand that the federal and provincial authorities have recommended that Ontarians stay home and avoid close contact with other people when at all possible. *

I understand.

2. I understand the federal and provincial authorities have asked individuals to maintain social distancing of a least two (2) meters (six (6) feet) and I recognize it is not possible to maintain this distance while receiving dental treatment. *

I understand.

3. I understand that oral surgery/dental procedures can create water and/or blood spray, which is one way that the novel coronavirus can spread. I understand that the ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus. *

I understand.

4. I understand that due to the visits of other 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 the dental office. *

I understand.

5. I confirm that I do NOT have any TWO OR MORE or the following symptoms of COVID-19: (i) fever, (ii) new or worsening cough, (iii) sore throat, (iv) runny nose or (v) headache. *

I confirm.

6. If I received COVID-19 test results in the past three (3) months, the last results I received were negative. *

Yes, the test results were negative. No I did not receive any test.

If applicable, approximate date of test:

Enter date.

Date of last negative test:

Enter date.

7. I confirm that I am not waiting for the results of a test for COVID-19. *

I confirm.

8. I confirm that this is not currently a period during which public health authorities required I self-isolate for 14 days. *

I confirm.

9. I confirm that I have been informed that The Concourse Dental Centre is up to date with any infection control guidelines set out by the Royal College of Dental Surgeons to protect the health and safety of patients and staff. *

I confirm.

10. I verify the information I have provided on this form is truthful and complete. I, knowingly and willingly, consent to have emergency, surgical or elective dental treatment completed during the COVID-19 pandemic. *

I verify.