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. *
Yes, I Do Understand It.
Are you presenting with any of the following symptoms of COVOID-19 identified by Public Health Services: *
Fever > 38°CChillsSore ThroatHeadacheShortness of BreathDifficulty BreathingFlue-like SymptomsPink eye (conjunctivities)Difficulty SwallowingCough (NEW OR WORSENING)Runny Nose (NOT RELATED TO ALLERGIES)Decrease or loss of sense of taste or smellUnexplained fatigue/malaise/muscle achesNausea/vomiting, diarrhea, abdominal painNONE OF THE ABOVE
IF OVER THE AGE OF 70 Years old; I confirm that I am not experiencing any of the following: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions. (IF YOU ARE ABOVE 70 YRS OF AGE AND EXPERIENCING ANY OF THE ABOVE, PLEASE DO NOT COME INTO THE OFFICE AND CONTACT OUR OFFICE TO SPEAK TO THE DENTIST). *
I AM NOT OVER 70 YEARS OLD.I AM OVER 70. YES, I DO CONFIRM THAT.
I confirm that I am not currently positive for the novel coronavirus. *
YES, I DO CONFIRM THAT.
I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus. *
YES, I DO CONFIRM THAT.
I verify that I have not returned to Ontario from any country outside of Canada or any other province in Canada whether by car, air, bus or train in the past 14 days. *
YES, I DO VERIFY THAT.
I verify that I have not been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by Public Health, the Communicable Disease Control or any other governmental health agency.*
YES, I DO VERIFY THAT.
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.*
YES, I DO UNDERSTAND IT.
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.*
YES, I DO UNDERSTAND IT.
I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to having dental treatment at this time.*
YES, I DO VERIFY THAT.
