Patient's Full Name (First AND Last):

Patient's Age:

Patient's Phone:

Patient's Email:

Q1: Did you receive your final (or second) vaccination dose more than 14 days ago?
       YES       NO   

Q2: Do you have any of the following symptoms?
       YES       NO   

• Fever and/or chills
• New onset of cough or worsening chronic cough
• Shortness of Breath
• Decrease of loss of sense of taste or smell
• Adults OVER 18: Unexplained Fatigue / Lethargy / Malaise / Muscle Aches (myalgias)
• Children UNDER 18: Nausea/Vomiting, Diarrhea

Q3: Have you tested postive for COVID-19 in the last 10 days or been told that you should be isolating?
       YES       NO   

If you answered NO to Q1, please proceed to Q4 and Q5. Only answer Q4 and Q5 if you are not fully immunized.

Q4: Have you traveled outside of Canada in the last 14 days?
       YES       NO   

Q5: Have you had close contact with a confirmed case of COVID-19 without wearing approproate PPE?
       YES       NO   

I understand that the SARS CoV-2 virus causes the disease known as COVID-19 and that it is currently a pandemic. I understand that the SARS CoV-2 virus 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 excercise caution when leaving home and otherwise avoid close contact with other people when possible.

I understand that federal and provincial authorities have asked individuals to maintain social distancing of at least 2 metres (6 feet) and I recognize it is not possible to maintain this distance while receiving dental treatment.

I understand that dental procedures can create water and/or blood spray, which is one way that the SARS CoV-2 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.

I understand that due to the visits of other patients, the characteristics of the SARS CoV-2 virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the novel coronavirus simply by being in the dental office..

I agree to complete a COVID-19 screening questionnaire as required by the Ministry of Health.

If I received COVID-19 test results in the past three (3) months, the last results I received were negative OR I received a letter from Public Health clearing me.

If applicable, approximate date of test:

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

I confirm that this is not currently a period during which public health authorities require that I self-isolate.

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