Dental Treatment Consent Form
Please see below for the dental treatment consent form items that will need to be signed once arriving at our office for your appointment.
This form will be provided to you so please do not bring in a copy. This form must be signed for all persons entering the dental treatment area. Note, a touchless temperature check will also be taken.
- I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.
- I understand that despite careful attention to sterilization, disinfection and use of personal barriers, there is still a chance that I could be exposed to an illness simply by being in a dental office.
- I understand that due to the nature of dental procedures, it is not always possible to maintain social distancing between patients, health care team members and sometimes other patients at all times.
- I confirm that I have not had close contact with anyone with acute respiratory illness or travelled outside of Canada in the past 14 days.
- I confirm that I do not have a confirmed case of COVID-19. I confirm that I have not been in close contact with any confirmed COVID-19 positive patients or persons self-isolating because of a determined risk for COVID-19. I confirm that I am not waiting for the results of a laboratory test for COVID-19.
- I confirm that I am not presenting any of the following symptoms of COVID-19 or have had any COVID-19 symptoms in the past 14 days:
- Fever
- New onset of cough
- Worsening chronic cough
- Shortness of breath
- Difficulty breathing
- Sore throat
- Difficulty swallowing
- Decrease or loss of sense of taste or smell
- Chills
- Headaches
- Unexplained fatigue/malaise/muscle aches (also known as “myalgias”)
- Nausea/vomiting, diarrhea, abdominal pain
- Pink eye (also known as “conjunctivitis”)
- Runny nose/nasal congestion without other known cause
- I confirm that I will inform office staff if I experience symptoms related to COVID-19 within the next 14 days.
- If I am over 70 years old, I confirm that I am not presenting any of the following symptoms:
- Delirium
- Unexplained or increased number of falls
- Acute functional decline
- Worsening of chronic conditions
From New Friends
Dear Dr Anna,
We just wanted to thank you for the kind and gentle manner in which you and your staff treated our family.
We appreciated the way you explained your procedures and thank you for the great service we received in your office.
We're so glad we found you!
Best regards,
Carlos, Claudia, and son Daniel (Richmond Hill)
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