• COVID-19 screening and dental treatment consent form

  • 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
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