Covid-19 Treatment Consent form

Due to the COVID-19 Pandemic we have instituted an additional dental treatment consent form. Please submit the form prior to arrival.

If you’re able to wear a mask to your appointment, please do so. Otherwise, we will provide you with one upon entry into the clinic.

Name *

First

Last

Patient Email *

Patient Mobile *

Are you currently a patient of 7DENTAL? *

I understand the novel coronavirus causes the disease known as COVID-19. 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. *

Confirm

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. *

Confirm

Are you presenting any of the following symptoms of COVID-19 identified by Public Health Services?

Fever > 38°C *

Cough (new or worsening chronic)

Sore Throat *

Shortness of Breath *

Difficulty Breathing *

Flu-like symptoms *

Nausea / vomiting, diarrhea, abdominal cramps (or unknown origin) *

Conjunctivitis (Pink Eye) *

Decrease of loss of sense of taste or smell *

Chills *

Headaches *

Unexplained Fatigue / Malaise / Muscle Aches *

Runny nose / nasal congestion without other known cause *

Have you tested positive for COVID-19 OR had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? *

Are you waiting for the results of a laboratory test for the novel coronavirus *

Have you returned to Ontario from any country outside of Canada whether by car, air, bus or train in the past 14 days. *

Have you been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by Public Health, the Communicable Disease Control or any other governmental health agency. *

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. Public Health requires self-isolation for 14 days from the date a person has returned to Canada. *

Confirm

I understand that Public Health has asked individuals to maintain physical distancing of at least 2 meters (6 feet) and it is not possible to maintain this distance and receive dental treatment. *

Confirm

I acknowledge and understand that there will be a modest fee applied during my visit. The COVID-19 pandemic has impacted the cost of delivering care, including the retrofitting of all dental operatory rooms, increased costs for PPE in high demand, and mandatory infection control measures as required by new provincial standards in order to protect the health and safety of all patients, staff and general public. *

Confirm

For patients who have dental benefits, it is the decision of each insurer or employer’s dental plan whether coronavirus-related fees will be covered under their policies. It is the patient’s responsibility to understand their own coverage. *

Confirm

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above listed dental treatment completed during the COVID-19 pandemic *

Confirm

Comment

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Covid-19 Treatment Consent Form

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Covid-19 Treatment Consent form

Printable format of above form

Covid-19 Treatment Consent Form

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