I confirm that I am not presenting any of the following symptoms of COVID-19 listed below:

• FEVER (feeling hot to touch, a temperature of 100 degrees Fahrenheit or higher)
• CHILLS
• COUGH that's new or worsening (continuous, more than usual)
• BARKING COUGH, making a whistling noise when breathing ('CROUP')
• SHORTNESS OF BREATH (out of breath, unable to breathe deeply)
• SORE THROAT
• DIFFICULTY SWALLOWING
• RUNNY NOSE (not related to seasonal allergies or other know causes or conditions)
• NASAL CONGESTION (not related to seasonal allergies or other known causes or conditions)
• LOSS OF SENSE OF SMELL
• PINK EYE (conjunctivitis)
• HEADACHE that's unusual or long-lasting
• DIGESTIVE ISSUES (nausea/vomiting, diarrhea, stomach pain)
• MUSCLE ACHES
• EXTREME TIREDNESS THAT IS UNUSUAL (fatigue, lack of energy)
• FALLING DOWN MORE THAN USUAL
• FOR YOUNG CHILDREN & INFANTS: Sluggishness or lack of appetite

I verify that I have not traveled outside of Canada in the past 14 days and have not been in touch with anyone with covid/potential covid in the last 14 days.

I, knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.

Thank you for doing your part in keeping everyone safe. Please note the following:

• wear a MASK when entering the dental office
• SANITIZE your hands immediately upon arrival
• maintain Social Distancing from other patients
• have your Temperature taken by our team members
• not have any Accompaniment except small child/caregivers/translators