Covid-19 Emergency Dental Treatment Consent Form

I knowingly and willingly consent to have emergency dental treatment completed during the COVID-19 pandemic.

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

I acknowledge and understand that dental procedures create water spray which is one way that the novel coronavirus can spread.

I understand that due to the frequency of visits of other dental 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 a dental office.

I confirm I know that there are categories of people who are considered to be high risk. I understand that the high risk category factors are being 65 years of age or older, heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder.

I fall into one of the above high risk categories and i have discussed these risks with my dentist and i have agreed to proceed with treatment.

I confirm that I am not presenting any of the following symptoms of COVID-19:

Fever > 38ºC

Cough (Initial)

Sore Throat (Initial)

Shortness of Breath (Initial)

Flu-like symptoms

I confirm that I am not currently positive for the novel coronavirus.

I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus.

I verify that I have not returned from any country outside of Canada in the past fourteen (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.

I verify that I have not been identified as a contact of someone who has tested positive for COVID-19 or been asked to self-isolate by Public Health

List of Dental Treatment

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above listed emergency dental treatment completed during the COVID-19 pandemic.

Signature of Patient

Printed Name

Date