COVID-19 Patient Screening and Treatment Consent

Please be advised that a Personal Protective Equipment (PPE) fee of $18 will be added to your invoice.
COVID-19 Patient Screening and Treatment Consent
Patient Name

First Name Last Name
Date of Birth

Month Day Year
Date
Please come to the Clinic entrance 5 minutes prior to your appointment time and stand at the designated spots by the front door. PLEASE DO NOT ENTER THE CLINIC UNTIL YOU ARE CALLED. Cell Phone Number where you can be contacted.

Area Code Phone Number
I understand the novel coronavirus causes 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. *
Initial
I understand that dental procedures create water spray, which is one 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. *
Initial
I understand that due to the presence of other dental patients, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have a risk of contracting the novel coronavirus by being in a dental office. *
Initial
Do you have any of the following symptoms of COVID-19 identified by Ontario Health Services?
Fever (Temperature equal to or above 38℃) *

No Yes
Cough *

No Yes
Shortness of Breath *

No Yes
Difficulty Breathing *

No Yes
Sore Throat *

No Yes
Difficulty Swallowing *

No Yes
Decrease or Loss of Sense of Taste or Smell *

No Yes
Chills *

No Yes
Headaches *

No Yes
Unexplained Fatigue/Malaise/Muscles Aches (Myalgias) *

No Yes
Nausea/Vomitting, Diarrhea, Abdominal Pain *

No Yes
Pink Eye (Conjunctivitis) *

No Yes
Runny Nose/Nasal Congestion without other known cause *

No Yes
Flu-like symptoms *

No Yes
If you are over 70 years of age or older, are you experiencing any of he following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of existing chronic conditions? *

No Yes Not Applicable (Younger than 70 years old)
I confirm that I have not received a positive diagnosis for the novel coronavirus in the past 14 days. *
Initial
I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus. *
Initial
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. *
Initial
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. Ontario Health Services require self-isolation for 14 days from the date a person has returned to Canada. *
Initial
I understand that Ontario Health Services 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. *
Initial
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 Ontario Health, the Communicable Disease Control or any other governmental health agency without wearing appropriate PPE. *
Initial
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.
SIGNATURE OF PATIENT *

Please use your mouse or track pad cursor. (On mobile devices, please use your finger). Clear
Printed Name *
Date *

Month Day Year
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:

Please be advised that a Personal Protective Equipment (PPE) fee of $18 will be added to your invoice.

***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.***

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.