COVID-19 Health Declaration Form (Phase 3)

COVID-19 Health Declaration Form (Phase 3)
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Your Appointment Date & Time (Please choose the closest one)*
In the past 14 days, have you been tested POSITIVE for COVID-19?*

YesNo
In signing below, I, an individual over the age of 18 of sound mind, knowingly, voluntarily, and freely agree to this Declaration, and in doing so represent the truthfulness and veracity of the above answers.
Signature*

COVID-19 TREATMENT RISK INFORMED CONSENT FORM
I understand that I am opting for an elective treatment/procedure that is not urgent and may not be medically necessary. I also understand that the novel coronavirus, COVID19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is spread by person-to-person contact; and, as a result, government and health authorities recommend social distancing.*
Initial here
I recognize that Dr. C. Lun Wang and Dr. Kevin Lee and all the staff at Pacificwest Dental Group and BC Head Pain Institute are closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19.However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with this elective treatment/procedure.*
Initial here
I hereby acknowledge and assume the risk ofbecoming infected with COVID-19 through this elective treatment/procedure, andI give my express permission for Dr. C. Lun Wang and Dr. Kevin Lee and all thestaff at Pacificwest Dental Group and BC Head Pain Institute to proceed withthe same.*
Initial here
I understand that, if I have a COVID-19 infection, and even if I do not have any symptoms for the same, proceeding with this elective treatment/procedure can lead to a higher chance of complication and death. I understand that possible exposure to COVID-19 before/during/after my treatment/procedure may result in the following: a positive COVID-19 diagnosis, extended quarantine/self-isolation, additional tests, hospitalization that may require medical therapy, Intensive Care treatment, possible need for intubation/ventilator support, short-term or long-term intubation, other potential complications, and the risk of death. In addition, after my elective treatment/procedure, I may need additional care that may require me to go to an emergency room or a hospital. I understand that COVID-19 may cause additional risks, some or many of which may not currently be known at this time, in addition to the risks described herein, as well as those risks for the treatment/procedure itself.*
Initial here
I have been given the option to defer my treatment/procedure to a later date. However, I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my desired treatment/procedure.*
Initial here
I UNDERSTAND THE EXPLANATION AND HAVE NO MORE QUESTIONS AND CONSENT TO THE PROCEDURE
Signature*
Signature Date*

MonthDayYear
Date
Should be Empty:

COVID-19 Health Declaration Form (Phase 3)

COVID-19 TREATMENT RISK INFORMED CONSENT FORM