Patient Forms

Patient Forms

* All patients must complete the COVID-19 Pre-Screening Form (downloadable or online form). New patients must also complete the Medical History Form.

COVID-19 Pre-Screening Form

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

Location:
Patient's Name:

E-mail:

I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Public Health Services:

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  • Fever > 38°C
  • Cough (New or Worsening)
  • Shortness of Breath
  • Difficulty Breathing
  • Sore Throat
  • Difficulty Swallowing
  • Decrease or loss of sense of taste or smell
  • Chills
  • Headaches
  • Unexplained fatigue / Malaise / Muscle Aches (myalgias)
  • Pink eye (conjunctivitis)
  • Runny nose / nasal congestion without other known cause
  • Nausea/vomiting, diarrhea, abdominal cramps (of unknown origin)

OR

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

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

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

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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. Canadian and 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 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.

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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.

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List of Dental Treatment:

Signature:

Printed Name: