Dental Treatment Consent Form

Patient name:

I understand the novel coronavirus cause 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.

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

I confirm that I am not presenting any of the following symptoms of COVID-19 identified by the Centres of Disease Control:

Fever > 38°C

No

Recorded Temperature °C

New cough or worsening chronic cough

No

Sore throat or painful swallowing

No

New or worsening shortness of breath

No

Difficulty Breathing

No

Flu-like symptoms

No

Runny Nose

No

I confirm I know that there are categories of people who are considered to be high risk. I understand the high risk category factors are being 65 years of age or older, heart disease , lung disease, kidney disease, diabetes or any auto-immune disorder.

I fall into the following risk categories and my dentist and I have discussed the risks, and I have agreed to proceed with treatment. I fall into the following risk categories and my dentist and I have discussed the risks, and I have agreed to proceed with treatment. <span class="frm_required" aria-hidden="true">*</span>

I confirm that to my knowledge I am not currently positive for the novel Coronavirus.

I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus.

I verify that I have not returned to B.C. from any country outside of Canada whether by car, air, bus, boat or train in the past 14 days.

I understand that any travel from any country outside of Canada, including travel by car, air, bus, boat, or train, significantly increases my risk of contracting and transmitting the novel coronavirus. The BC health Authority requires self-isolation for 14 days from the date a person and returned to Canada.

I understand that the BC Health Authority has asked individuals to maintain physical distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive dental treatment.

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 the BC Health Authority, the Communicable Disease Control or any other governmental health agency.

I verify that I am a healthcare worker who has worn appropriate PPE.

List of DENTAL TREATMENT

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.

Printed Name

Date

COVID-19 Pandemic Dental Treatment Consent Form

COVID-19 Pandemic Dental Treatment Consent Form

I confirm that I am not presenting any of the following symptoms of COVID-19 identified by the Centres of Disease Control: