COVID-19 Pandemic Dental Treatment Consent Form

COVID-19: Screening & Consent

Westpointe Dental Centre
Patient Information
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Phone Number *

Area Code Phone Number
Email *
example@example.com

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

YES

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:

COVID-19: Screening & Consent

Patient Information