westborodental.ca

Name*

First Last

Date Of Birth*

Have you been completely vaccinated for COVID-19?*

YES
NO
PREFER NOT TO ANSWER

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?*

YES
NO

Are you/they having shortness of breath or other difficulties breathing?*

YES
NO

Do you/they have a cough?*

YES
NO

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*

YES
NO

You selected YES, Please provide more details*

Have you/they experienced recent loss of taste or smell?*

YES
NO

Are you/they in contact with any confirmed COVID-19 positive patients?*

YES
NO

Is your/their age over 60?*

YES
NO

Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*

YES
NO

Have you/they traveled in the past 14 days outside your state? (as relevant to your location)*

YES
NO

Where have you traveled to?*

Have you been tested positive to COVID-19?*

YES
NO

When did you get tested positive to COVID-19?*

Have you been tested again as negative to COVID-19?*

YES
NO

When did you get tested negative to COVID-19?*

Patients who are well but who have a sick family member at home with COVID-19 should consider postponing/rescheduling treatment. Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with dental treatment.

Patient Acknowledgement*

I understand the novel coronavirus causes the disease known as COVID19 and that it is currently a pandemic. I understand that the novel coronavirus 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 stay home and avoid close contact with other people when at all possible. I understand the federal and provincial authorities have asked individuals to maintain physical distancing of at least 2 meters or six feet and I recognize it is not possible to maintain this distance while receiving dental treatment. I understand that oral surgery/dental procedures can create water and/or blood spray, which is one way that the novel coronavirus 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 novel coronavirus, 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 confirm that I do NOT have any ONE OR MORE of the following symptoms of COVID-19: (i) fever, (ii) new or worsening cough, (iii) sore throat, (iv) runny nose or (v) headache, (vi) loss of sense of smell and taste. If I received COVID-19 test results in the past three months, the last results I received were negative. I confirm that I am not waiting for the results of a test for COVID-19. I confirm that this is not currently a period during which public health authorities required I self-isolate for 14 days. I verify the information I have provided on this form is truthful and complete. I knowingly and willingly consent to have emergency and non-emergency surgical/dental treatment completed during the COVID-19 pandemic

I agree to above mentioned consent.

Signature of Patient or Legal Guardian*

Today's Date: 09/09/2024

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Consent Text

I understand the novel coronavirus causes the disease known as COVID19 and that it is currently a pandemic. I understand that the novel coronavirus 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 stay home and avoid close contact with other people when at all possible.
I understand the federal and provincial authorities have asked individuals to maintain physical distancing of at least 2 meters or six feet and I recognize it is not possible to maintain this distance while receiving dental treatment. 
I understand that oral surgery/dental procedures can create water and/or blood spray, which is one way that the novel coronavirus 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 novel coronavirus, 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 confirm that I do NOT have any ONE OR MORE of the following symptoms of COVID-19: (i) fever, (ii) new or worsening cough, (iii) sore throat, (iv) runny nose or (v) headache, (vi) loss of sense of smell and taste. 
If I received COVID-19 test results in the past three months, the last results I received were negative. 
I confirm that I am not waiting for the results of a test for COVID-19.
I confirm that this is not currently a period during which public health authorities required I self-isolate for 14 days. 
I verify the information I have provided on this form is truthful and complete. I knowingly and willingly consent to have emergency and non-emergency surgical/dental treatment completed during the COVID-19 pandemic

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Westboro Dental Clinic