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COVID-19 Pandemic Dental Risk Consent
Fairway Dental Clinic
385 Fairway Road South, Unit #203
Kitchener, Ontario, Canada N2C 2N9
Phone: 519-893-9494
Today's Date
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Date Format: DD slash MM slash YYYY
Patient Name
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First
Middle
Last
Date of Birth
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MM
YYYY
Age
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Home Phone
Cell Phone
Email
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Work Phone
Extension Number
Date of Appointment
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Time
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Please read the patient acknowledgement below, and check off each point confirming your understanding of given point.
I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand the novel coronavirus has a long incubation period during which carriers of the virus
may not show symptoms and still be contagious
. For this reason, it is recommended to stay home and avoid close contact with other people when at all possible.
I understand the federal and provincial governments have asked individuals to maintain social distancing of at least 2 metres (6 Feet) and I recognize it is
not possible to maintain this distance while receiving dental treatment
.
I understand that oral surgery/dental procedures can create water and / or blood spray, which is one important way that the novel coronavirus can spread. 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 novel coronavirus, and the characteristics of dental procedures,
that I have an elevated risk of contracting AND SPREADING the
novel coronavirus simply by being in the dental office
.
I confirm that I do NOT have any of the following symptoms of COVID-19: fever, new or worsening cough, sore throat, runny nose or headache.
I confirm that I have not tested positive for COVID-19.
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 where I required to self-isolate for 14 days.
Consent
I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have emergency surgical/dental treatment completed during the COVID-19 pandemic.
Patient Signature (Write your Name)
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Date
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