COVID-19 Pandemic Dental Treatment Consent Form

Pre=Examination Protocol (Answer YES/NO to the following) *

	YES	NO
Flu like symptoms
Fever
New cough or worsening chronic cough
Sore throat or painful swallowing
Difficulty Breathing
New or worsening Shortness of Breath
Muscle Pain
Loss of taste or smell
Travel outside of Canada within the past 14 days
Contact with COVID-19 or Family Member contact COVID-19 symptoms
Waiting for the results of laboratory test for the COVID-19 virus
Is your workplace considered high risk? (Healthcare workers wearing appropriate PPE can answer 'no")
I understand that there are high risk category factors such as being over 65 years of age, heart disease, lung disease, kidney disease or any Auto-immune disorder.
I understand the risks, and have agreed to proceed with treatment.

Please note: Carriers of COVID-19 may not exhibit any symptoms and the virus can have an incubation period of up to 14 days. Social distancing of 2 meters helps reduce the spread of COVID -19, but is not always possible to maintain during dental treatment.

I knowingly and willingly consent to having dental treatment completed by the doctors and staff.
Patient/Parent/Guardian Signature *

Clear
Signed Date *

Month Day Year
Date Hour Minutes AM/PM Option
Should be Empty:

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COVID-19: Screening & Consent