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.


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

Factors such as old age, diabetes and end-stage renal disease are generally not considered immunocompromised. Examples of being immunocompromised include individuals:

    • undergoing cancer chemotherapy
      with untreated HIV infection with CD4 T lymphocyte count less than 200
      with combined primary immunodeficiency disorder
      on prednisone medication - more than 20 mg per day (or equivalent) for more than 14 days
      on other immune suppressive medications.
  • Printable format of above form