COVID-19 Health Declaration Form (Phase 3)

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

First Name Last Name
Date of Birth *

Month Day Year
Date
Your Appointment Date & Time (Please choose the closest one) *
In the past 14 days, have you or any household member traveled internationally (China, US,Iran, Italy, Japan, South Korea, and any European country) or anywhere in the world? *

Yes No
In the past 14 days, have you or any household member had any contact with a COVID-19 patient or people with COVID-19 alike symptoms? *

Yes No
Have you or any household member have a history of exposure to COVID-19 biologic material? *

Yes No
Have you or any household member show any symptoms of COVID-19 (fever, cough, shortness of breath…etc) in the past 14 days? *

Yes No
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 *

Clear

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) *
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) *
I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment/procedure, and I give my express permission for Dr. C. Lun Wang and Dr. Kevin Lee and all the staff at Pacificwest Dental Group and BC Head Pain Institute to proceed with the same. (Initial) *
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) *
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) *
I UNDERSTAND THE EXPLANATION AND HAVE NO MORE QUESTIONS AND CONSENT TO THE PROCEDURE
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

COVID-19 Health Declaration Form (Phase 3)

COVID-19 TREATMENT RISK INFORMED CONSENT FORM