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HOME
ABOUT
Reviews Us
SERVICES
Emergency Dental Exams
Dental X-Rays
Cuts & Lacerations
Dental Root Canal
Dental Filling Cavities
Crowns & Bridges
Repair Broken Teeth, Fillings, Crowns & Dentures
Replacement Of Fillings & Crowns
Removal Of Foreign Bodies
Treatment Complications
STUDENT CARE
PATIENT INFORMATION
Patient Forms
New Patient Form
Medical History Update
5 Year Medical Update Form
Patient Screening Form
COVID-19 Pandemic Dental Risk Consent
BLOG
News
SERVICE AREAS
Kitchener Ontario
Alpine Ontario
Bridgeport-Ontario
Brigadoon-Ontario
Centreville-Ontario
Country Hills West-Ontario
View All Areas
BOOK AN APPOINTMENT
COVID-19 Pandemic Dental Risk Consent
Fairway Dental Clinic
385 Fairway Road South, Unit #203
Kitchener, Ontario, Canada N2C 2N9
Phone: 519-893-9494
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Patient Name
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Who is Filling Out This Form?
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Please Specify
Please read the patient acknowledgement below, and check off each point confirming your understanding of given point.
I understand the SARS CoV-2 virus causes the disease known as COVID-19 and that it is currently a pandemic. I understand that the SARS CoV-2 virus has an 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 exercise caution.
I understand that oral surgery/dental procedures can create water and/or blood spray, which is one way that the SARS CoV-2 virus 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 SARS CoV-2 virus, and the characteristics of dental procedures,
I have an elevated risk of contracting the novel coronavirus simply by being in the dental office.
I agree to complete a COVID-19 screening questionnaire as required by the Ministry of Health.
If I received COVID-19 test results in the past 10 days, the last results I received were negative OR I have completed the required isolation period as indicated by public health authorities.
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 me to self-isolate.
Consent
I verify the information I have provided on this form is truthful and complete. I knowingly and willingly consent to dental treatment completed during the COVID-19 pandemic.
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