Patient Acknowledgement of COVID-19 Pandemic Risk

Patient Acknowledgement of COVID-19 Pandemic Risk

Please read this form and sign where indicated.
1) I understand there is currently a health pandemic associated with COVID-19 and the novel coronavirus.

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2) I understand public health authorities have recommended maintaining social distancing of a least 2 metres (6 feet) and it is not possible to maintain this distance while receiving dental treatment.

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3) I understand that oral surgery/dental procedures can create water and/or bloody spray, and that there may be an elevated risk of contracting and spreading the novel coronavirus in a dental office.

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4) I confirm that I do not have any of the following symptoms of COVID-19: fever, dry cough, sore throat or painful swallowing, runny nose, sneezing or post-nasal drip, loss of smell, taste or appetite, headache, chills, muscle aches, or fatigue and that this is not currently a period where I am required to self-isolate for 14 days.

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5) I confirm that I have not tested positive for COVID-19 and that I am not currently waiting for the results of a test for COVID-19.

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6) I hereby consent to have dental treatment completed during the COVID-19 pandemic.

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Adapted from the Dental Association of PEI COVID-19 Pandemic Emergency Dental Risk Acknowledge by Patient.
By checking the box below and typing my name below, I am electronically signing this consent form.

PATIENT’S (OR LEGAL GUARDIAN’S) CONSENT
I, First Name Last Name state that all the answers given in this consent form are truthful.
Date Signature
Should be Empty:

Patient Acknowledgement of COVID-19 Pandemic Risk

By checking the box below and typing my name below, I am electronically signing this consent form.