PATIENT SCREENING AND ACKNOWLEDGMENT

I UNDERSTAND THE NOVEL CORONAVIRUS CAUSES THE DISEASE KNOWN AS COVID-19 AND THAT IT IS CURRENTLY A PANDEMIC. I UNDERSTAND THAT THE NOVEL CORONAVIRUS HAS A LONG INCUBATION PERIOD DURING WHICH CARRIERS OF THE VIRUS MAY NOT SHOW SYMPTOMS AND STILL BE CONTAGIOUS. FOR THIS REASON, I UNDERSTAND THAT THE FEDERAL AND PROVINCIAL AUTHORITIES HAVE RECOMMENDED THAT ONTARIANS STAY HOME AND AVOID CLOSE CONTACT WITH OTHER PEOPLE WHEN AT ALL POSSIBLE (required)

I UNDERSTAND THE FEDERAL AND PROVINCIAL AUTHORITIES HAVE ASKED INDIVIDUALS TO MAINTAIN SOCIAL DISTANCING OF AT LEAST TWO (2) METERS (SIX (6) FEET) AND I RECOGNIZE IT IS NOT POSSIBLE TO MAINTAIN THIS DISTANCE WHILE RECEIVING DENTAL TREATMENT(required)

I UNDERSTAND THAT ORAL SURGERY/DENTAL PROCEDURES CAN CREATE WATER AND/OR BLOOD SPRAY, WHICH IS ONE WAY THAT THE NOVEL CORONAVIRUS CAN SPREAD. I UNDERSTAND THAT THE ULTRA-FINE NATURE OF THE SPRAY CAN LINGER IN THE AIR FOR MINUTES TO SOMETIMES HOURS, WHICH CAN TRANSMIT THE NOVEL CORONAVIRUS(required)

I UNDERSTAND THAT DUE TO THE VISITS OF OTHER PATIENTS, THE CHARACTERISTICS OF THE NOVEL CORONAVIRUS, AND THE CHARACTERISTICS OF DENTAL PROCEDURES, THAT I HAVE AN ELEVATED RISK OF CONTRACTING THE NOVEL CORONAVIRUS SIMPLY BY BEING IN THE DENTAL OFFICE(required)

I AGREE TO COMPLETE A COVID-19 SCREENING QUESTIONNAIRE AS REQUIRED BY THE MINISTRY OF HEALTH(required)

IF I RECEIVED COVID-19 TEST RESULTS IN THE PAST THREE (3) MONTHS, THE LAST RESULTS I RECEIVED WERE NEGATIVE(required)

IF I RECEIVED COVID-19 TEST RESULTS IN THE PAST THREE (3IF APPLICABLE, APPROXIMATE DATE OF TEST(required)

IF I RECEIVED COVID-19 TEST RESULTS IN THE PAST THREE (3IF APPLICABLE, APPROXIMATE DATE OF TEST

IF I RECEIVED COVID-19 TEST RESULTS IN THE PAST THREE (3IF AI CONFIRM THAT I AM NOT WAITING FOR THE RESULTS OF A TEST FOR COVID-19(required)

I CONFIRM THAT THIS IS NOT CURRENTLY A PERIOD DURING WHICH PUBLIC HEALTH AUTHORITIES REQUIRED I SELF-ISOLATE FOR 14 DAYS(required)

I VERIFY THE INFORMATION I HAVE PROVIDED ON THIS FORM IS TRUTHFUL AND COMPLETE. I KNOWINGLY AND WILLINGLY CONSENT TO HAVE EMERGENCY SURGICAL/DENTAL TREATMENT COMPLETED DURING THE COVID-19 PANDEMIC (required)

Date

PATIENT SCREENING AND ACKNOWLEDGMENT

PATIENT SCREENING

QUESTIONS

PATIENT ACKNOWLEDGMENT

COVID-19 PANDEMIC EMERGENCY DENTAL RISK

PATIENT SCREENING AND ACKNOWLEDGMENT

PATIENT SCREENING

QUESTIONS

PATIENT ACKNOWLEDGMENT

COVID-19 PANDEMIC EMERGENCY DENTAL RISK

Share this: