Please note that in accordance with regulations mandated by the Royal College of Dentists Surgeons of Ontario, our office is required to have this screening form completed before entering our office. Thank-you for your understanding and patience which in turn enables us to not only comply with this College requirement, but to also do everything in our power to keep our patients, staff and our families safe during these challenging times.

CONSENT TO TREATMENT

I consent to receive treatment from Brantford North Dental during the COVID-19 pandemic. I understand that Public Health Ontario and the Royal College of Dental Surgeons of Ontario ("RCDSO") guidelines have allowed proceeding with any treatment that is non-emergency or not urgent at this time.

Our Practice follows all the Public Health Ontario and RCDSO guidelines for infection control of COVID-19 in providing emergency, urgent or elective dental treatments. This is a more rigorous regimen than what we normally maintain. The staff will be wearing additional Personal Protective Equipment (PPE), the offices has isolated treatment rooms with plastic tarpaulins, rooms are left fallow between patients and heavily disinfected, and there is enhanced air filtration.

We are employing these measures to minimize the risk of transmission of COVID-19 between patients. Despite this and due to: the unknowns of the COVID-19 virus; the number of other patients that have been in the Practice; and the nature of the procedures performed here; there may be a risk of contracting the virus by being in, and by receiving treatment at, the Practice.

By signing below, I acknowledge that

I have read and understand the CONSENT TO TREATMENT paragraphs noted above

That I have clicked on the link provided above to the Ontario Covid-19 Assessment WITHIN THE PAST HOUR and have answered all of its questions accurately and honestly and then relayed this information onto this form as per the following question.