I understand the novel coronavirus causes the disease known as COVID-19 and has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. *

Yes

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. *

Yes

I understand that due to the frequency of visits of other dental patients, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have an elevated risk of contracting the novel coronavirus simply by being in a dental office *

Yes

I am not currently positive for the novel coronavirus. *

Yes

Do you or have you had any flu-like symptoms in the last 14 days? *

o Cough o Shortness of Breath o Fever >38C o Chills o Repeated shaking o Fatigue o Muscle aches o Vomiting o Headache o Sore throat o New loss of taste or smell o Malaise o Nausea o Diarrhea

Yes

No

Are you awaiting results of a lab test for COVID-19? *

Yes

No

Have you tested positive for COVID-19? When? *

Yes

No

Have you or a family member previously been asked to self-isolate or quarantine in the past 14 days? *

Yes

No

Have you had close contact to an individual diagnosed with COVID-19 infection in the past 14 days? *

Yes

No

Have you traveled outside of Ontario in the past 14 days to a region with high rates of COVID-19 disease activity? *

Yes

No

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. Canadian and Ontario Health Services require self-isolation for 14 days from the date a person has returned to Canada. *

Yes

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. *

Yes

Patient Name *

First Name

Last Name

Guardian Name

Required, if patient is under 18 years of age.

First Name

Last Name

Date *

MM

DD

YYYY

By submitting this agreement, I understand the conditions of this form and I consent to the use of my first name, last name and email that I have entered above as an adult and/or guardian to be used as an electronic signature in lieu of an original signature on paper. *

Yes