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Covid Consent Form

"*" indicates required fields

Patient name*
Have you traveled outside of Canada in the last 14 days?
Following AHS guidelines, have I been asked or required to self-isolate due to a current positive Covid status or being a confirmed close contact?*
Do you have any new onset (or worsening) of the following symptoms:*
Shortness of breath*
Runny nose*
Sore throat*
Painful swallowing*
Nasal congestion*
Feeling unwell / fatigued*
Nausea / vomiting / diarrhea*
Unexplained loss of appetite*
Loss of sense of taste or smell*
Muscle / joint aches*
Conjunctivitis (commonly known as pink eye)*

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

MM slash DD slash YYYY
Time of Appointment*

CMOH Order 05-2020 legally obligates any person who has the following core symptoms of cough, fever, shortness of breath, runny nose, or sore throat (that is not related to a pre-existing illness or health condition) to be in isolation (quarantine) for 10 days from the start of symptoms, or until symptoms resolve, whichever takes longer, or they receive a negative COVID Test. If they are exhibiting any of these symptoms, it is suggested they complete the COVID-19 Self-Assessment online tool to determine if they should be tested.