COVID-19 Dental Treatment Consent Form

I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Ontario Health Services:

• Fever
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• Cough
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• Sore Throat
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• Difficulty Breathing
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• Flu-like Symptoms
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• Runny Nose
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• Conjunctivitis (Pink Eye)
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• Decrease or loss of sense of taste or smell
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• Chills
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• Headaches
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• Unexplained Fatigue / malaise / muscle aches
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• Nausea/vomiting, diarrhea, abdominal pain
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• Difficulty swallowing
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• Unexplained or increased number of falls
• Delirium
• Acute functional decline
• Worsening of chronic conditions

OR

I confirm that I do not have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19.

I confirm that I am not waiting for the result of a test for COVID-19.

I verify that I have not been asked to self-isolate by Public Health, or any other health agency for 14 days.

I understand that Public Health has asked individuals to maintain social distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive dental treatment.