King Street Dental Centre COVID consent form

King Street Dental Centre Covid Consent form

This form is a requirement before entering our building
Name *

First Name Last Name
please note that the REGION OF WATERLOO has a bi-law currently in place making masks mandatory in public setting. If you cannot wear a mask for medical reasons of ANY KIND please inform us prior to your appointment as we may have to reschedule you, as we cannot guarantee that social distancing (6 feet separations) can happen at all times while you are in the common areas. We thank you all for your co-operation during this time.

**FACE SHIELDS WILL NOT DO, ANY TYPE OF NON-MEDICAL OR MEDICAL MASK IS THE ONLY FACE COVERING ACCEPTED AT THIS TIME**
1. In the past 14 days, have you or any member of your household, traveled to any areas with known cases of COVID 19? *

Yes No
1.1 IF YES: Please state the exact location
IF NO: Skip question
2. In the past 14 days, have you or any member of your household has had any contact with any COVID-19 patient? *

Yes No
3. Have you had any history of fever for the last 14 days? *

Yes No

4. Have you had any symptoms in the last 14 days such as: *

5. Have you had any COVID-19 test? *

Yes No
5.1 IF YES: When was the date of last test?

Month Day Year
IF NO: Skip question
5.2 IF YES: What was the result of the test?
IF NO: Skip question

INFORMED CONSENT *

	Yes	No
I give my full consent to have dental treatment done to me or my child(ren) in this time of pandemic caused by COVID-19 disease
I am aware that the virus can be transmitted by contact through surfaces and that it can be infective for 5 to 72 hours. I am aware that this is impossible to identify who is probable, suspect or COVID-19 positive.
I recognize that the clinic is adhering to the strictest infection control protocols for my protection.
I fully understand the risk that because of the nature of the virus, by simply leaving my home, travelling to the clinic, the clinical procedures, and even by simply staying in the dental clinic, there is a chance of contracting the virus. Should I contract the virus, I hereby agree that I shall not hold the dental office liable.
I recognize that this clinic has a MANDATORY mask rule in effect, and I hereby agree to wear a mask when in common areas of the clinic.
I recognize that this clinic does not allow guests in with patients unless accompanying a minor (12 years or younger and only 1 parent or guardian is allowed in) and that their waiting room is closed and I may potentially have to wait outside before my treatment room is ready.

For the good of the entire community, I am TRUTHFULLY answering the questionnaire and fully understand the informed consent form:

Please sign your signature here Clear
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King Street Dental Centre Covid Consent form