NYD COVID-19 PANDEMIC DENTAL TREATMENT CONSENT FORM

Patient name: *

First Name Last Name

Email: *

example@example.com

I confirm that, to my knowledge, I am not currently positive for COVID-19 and am required to isolate in accordance with Ontario provincial health guidelines. *

Confirm

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

Confirm

Please note: If applicable, any individual who has gone in for testing on their own volition as an asymptomatic individual does not need to indicate this.

For patients over 18 years of age, I confirm that I am not presenting any of the following core symptoms of COVID-19 as identified by Public Health Ontario:

I do not have a fever > 38°C I do not have a new cough or worsening chronic cough I do not have a sore throat or painful swallowing I do not have a new or worsening shortness of breath I do not have difficulty breathing I do not have flu-like symptoms (including nausea/vomiting and fatigue) I do not have a runny nose I do not have an unexplained rash I have not experienced a recent loss of smell or taste

For patients under 18 years of age, I (as a parent or guardian) confirm that they are not presenting any of the following core symptoms of COVID-19 as identified by Public Health Ontario:

I do not have a fever > 38°C I do not have a new cough or worsening chronic cough I do not have a sore throat or painful swallowing I do not have a new or worsening shortness of breath I do not have difficulty breathing I do not have flu-like symptoms (including nausea/vomiting and fatigue) I do not have a runny nose I do not have an unexplained rash I have not experienced a recent loss of smell or taste

I confirm that, to my knowledge, I have not come into contact with someone who has tested positive for COVID-19 and am required to isolate in accordance with Ontario provincial health guidelines. *

Confirm

I confirm that I am not currently subject to a public health or government-mandated quarantine or period of self-isolation. *

Confirm

List of Dental Treatment Required:

I verify the information I have provided on this form is truthful and accurate. I acknowledge that being in a dental clinic increases my risk of contracting COVID-19. I knowingly and willingly consent to have all required and/or recommended dental treatment completed during the COVID-19 pandemic. Please use your mouse or finger to sign below. *

(Signature) Clear

Printed Name: *

First Name Last Name

Date: *

Date

COVID-19 Pandemic Dental Treatment Consent Form