• COVID-19 Patient Screening and Treatment Consent

  •  -  -
    Pick a Date
  •  -
  • Do you have any of the following symptoms of COVID-19 identified by Ontario Health Services?
  • I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.

  • Clear
  •  /  /
    Pick a Date
  • ***Due to Covid-19, we request that everyone (patients, parents and accompaning persons) presenting to Rideau Dental Centre wear a mask and bring their own pen in case a signature is needed.***

  •  
  • Should be Empty: