Covid-19 Health Declaration Consent Form

How are you feeling today?

My body temperature is lower than 98.6°F/ 37.5°C 

I am not experiencing the symptoms: fever, cough, sore throat  

I haven’t travelled outside of Canada nor been in close contact with a Covid-19 patient in the last 14 days

I confirm that this is not currently a period during which public health authorities required I self-isolate for 14 days.

I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. For this reason, it is recommended to stay home and avoid close contact with other people when at all possible

 

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

I understand the federal and provincial governments have asked individuals to maintain social distancing of a least 2 meters (6 feet) and I recognize it is not possible to maintain this distance while receiving dental treatment

 

I understand that it is possible that oral surgery/dental procedures can create water and/or blood spray, which may be 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.  

 

I confirm that I do NOT have any two or more of the following symptoms of COVID-19: fever, new or worsening cough, sore throat, runny nose or headache

 

I confirm that I have not tested positive for COVID-19. 

I confirm that I am not waiting for the results of a test for COVID-19.

 

I confirm that this is not currently a period where I required to self-isolate for 14 days.     

I have been advised that patients considered high risk for severe COVID-19 include those with pre-existing conditions such as serious respiratory disease, serious heart conditions, immunocompromised conditions, severe obesity, diabetes, chronic kidney disease or those undergoing dialysis, and liver disease; pregnant patients; and patients who are 70 years and over. I have been advised that if I am considered high risk that my treatment should be deferred whenever possible. 

Your Signature

Erin Dental Care

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Email us: smile@erindental.ca
Tel: (519) 833-0563
Address: 9565 Wellington Rd. 124 Erin, N0B 1T0, Ontario, Canada

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