TTC DENTAL COVID-19 PANDEMIC DENTAL TREATMENT CONSENT FORM

COVID-19 Pandemic Dental Treatment Consent Form
Patient name: *

First Name Last Name
Email: *
example@example.com
CMOH Order 35-2021 legally obligates any person who has the following core symptoms of cough, fever, shortness of breath, runny nose, or sore throat (that is not related to a pre-existing illness or health condition) to be in isolation for 10 days from the start of symptoms, or until symptoms resolve, whichever takes longer, or they receive a negative COVID Test. If they are exhibiting any of these symptoms, it is suggested they complete the COVID-19 Self-Assessment online tool to determine if they should be tested.
I confirm that I am not presenting any of the core symptoms of COVID-19 as identified above. *

Confirm
I confirm that, to my knowledge, I am not currently positive for COVID-19. *

Confirm
I confirm that, to my knowledge, I have not come into contact with someone who has tested positive for COVID-19 in the past 14 days. *

Confirm
I confirm I am not waiting for results of a COVID-19 test that was ordered in the past 14 days. *

Confirm
I confirm that I am not currently subject to a public health or government-mandated quarantine. *

Confirm
List of Dental Treatment Required:
I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have all required and/or recommended dental treatment completed during the COVID-19 pandemic. Please use your mouse or finger to sign below. *

(Signature) Clear
Printed Name: *

First Name Last Name
Date: *

Month Day Year
Date
Should be Empty:

COVID-19 Pandemic Dental Treatment Consent Form