COVID-19 Patient Pre-Screening Form

2525 Old Bronte Rd. Suite# 290, Oakville, ON, L6M 4J2 905-815-8888

Due to the COVID-19 Pandemic we have instituted an additional dental treatment consent form. Please submit the form prior to arrival.

PLEASE BRING YOUR OWN MASK OR FACE COVERING. YOU WILL BE ASKED TO USE OUR HAND SANITIZER UPON ENTERING AND LEAVING THE OFFICE.

Personal Information

Patient's Name:

Patient's Email:

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.

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I understand that dental procedures create water spray, which is one way that the novel coronavirus can spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus.

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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.

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

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I confirm that I am not experiencing any flu-like symptoms in the last 14 days:

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Cough
Shortness of Breath
Fever > 38°C
Chills
Repeated Shaking
Fatigue
Muscle Aches

Vomiting
Headache
Sore Throat
New loss of taste or smell
Malaise
Nausea
Diarrhea

Yes, I am awaiting results of a lab test for COVID-19.

Yes, I have tested positive for COVID-19 Date Tested Positive:

Yes, I or a family member have been asked to self-isolate or self-quarantine in the past 14 days.

Yes, I have had close contact to an individual diagnosed with COVID-19 infection in the past 14 days.

Yes, I have travelled outside of Ontario in the past 14 days to a region with high rates of COVID-19 disease activity.

If you have answered yes to any of the above questions, delay elective treatment for 14 days, then re-evaluate.

I understand that any travel from any country outside of Canada, including travel by car, air, bus or train, significantly increases my risk of contracting and transmitting the novel coronavirus. Ontario Health Services require self-isolation for 14 days from the date a person has returned to Canada.

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I understand that Ontario Health Services 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.

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