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Appointment Request
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Location Information
Please choose the Location(s) you wish to attend:
*
Central Park
Blossom Park
Findlay Creek
Tenth Line
Trim Social
Knata South
Any Location
Patient information
Your Name:
*
First
Last
Date of birth:
*
YYYY dash MM dash DD
Sex:
*
Please Select
Female
Male
Other
Your Email:
*
Phone
*
Is this a mobile number ?
*
Yes
No
Are you already a patient of 7Dental?
*
Yes
No
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Current 7Dental Location:
*
Central Park
Blossom Park
Findlay Creek
Tenth Line
Trim Social
Knata South
What type of appointment would you like?
Complete Oral Exam
Dental Cleaning & Checkup
Denture Consult
Ortho Consultation
Invisalign™ Free Smile Assessment
Other
type of appointment would you like:
How did you hear about us?
Google Search
Postcard
Digital Ad
Instagram
Facebook
Elevator Ad
Location
Friends
Appointment Request
Request Appointment
Location Information
Please choose the Location(s) you wish to attend:
*
Central Park
Blossom Park
Findlay Creek
Tenth Line
Trim Social
Knata South
Any Location
Patient information
Your Name:
*
First
Last
Date of birth:
*
YYYY dash MM dash DD
Sex:
*
Please Select
Female
Male
Other
Your Email:
*
Phone
*
Is this a mobile number ?
*
Yes
No
Are you already a patient of 7Dental?
*
Yes
No
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Current 7Dental Location:
*
Central Park
Blossom Park
Findlay Creek
Tenth Line
Trim Social
Knata South
What type of appointment would you like?
Complete Oral Exam
Dental Cleaning & Checkup
Denture Consult
Ortho Consultation
Invisalign™ Free Smile Assessment
Other
type of appointment would you like:
How did you hear about us?
Google Search
Postcard
Digital Ad
Instagram
Facebook
Elevator Ad
Location
Friends
ABOUT
LOCATIONS
All Locations
Central Park
Blossom Park
Findlay Creek
Tenth Line
Trim Social
Kanata South
SERVICES
Family and Kids Dentistry
Cosmetic Dentistry
Orthodontics
Sedation Dentistry
TMJ Therapy
Oral Surgery
Emergency Services
INVISALIGN
About Invisalign
For Teens
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FORMS
Standard Dental Claim
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Menu
ABOUT
LOCATIONS
All Locations
Central Park
Blossom Park
Findlay Creek
Tenth Line
Trim Social
Kanata South
SERVICES
Family and Kids Dentistry
Cosmetic Dentistry
Orthodontics
Sedation Dentistry
TMJ Therapy
Oral Surgery
Emergency Services
INVISALIGN
About Invisalign
For Teens
For Adults
Treatment Process
Invisalign vs. Braces
FAQs
SPECIALTIES
Orthodontics
Endodontics
Periodontics
Prosthodontics
PATIENTS
New Patients
Students
Anxious Patients
Insurance
Pay Online
FORMS
Standard Dental Claim
Full Medical History
Insurance Information and Agreement
Appointment Request
Request Appointment
Location Information
Please choose the Location(s) you wish to attend:
*
Central Park
Blossom Park
Findlay Creek
Tenth Line
Trim Social
Kanata South
Any Location
Patient information
Your Name:
*
First
Last
Date of birth:
*
YYYY dash MM dash DD
Sex:
*
Please Select
Female
Male
Other
Your Email:
*
Phone
*
Is this a mobile number ?
*
Yes
No
Are you already a patient of 7Dental?
*
Yes
No
Address
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Current 7Dental Location:
*
Central Park
Blossom Park
Findlay Creek
Tenth Line
Trim Social
Knata South
What type of appointment would you like?
Complete Oral Exam
Dental Cleaning & Checkup
Denture Consult
Ortho Consultation
Invisalign™ Free Smile Assessment
Other
type of appointment would you like:
How did you hear about us?
Google Search
Postcard
Digital Ad
Instagram
Facebook
Elevator Ad
Location
Friends
Recaptcha
Dental Emergency
Pay online
ABOUT
LOCATIONS
All Locations
Central Park
Blossom Park
Findlay Creek
Tenth Line
Trim Social
Kanata South
SERVICES
Family and Kids Dentistry
Cosmetic Dentistry
Orthodontics
Sedation Dentistry
TMJ Therapy
Oral Surgery
Emergency Services
INVISALIGN
About Invisalign
For Teens
For Adults
Treatment Process
Invisalign vs. Braces
FAQs
SPECIALTIES
Orthodontics
Endodontics
Periodontics
Prosthodontics
PATIENTS
New Patients
Students
Anxious Patients
Insurance
Pay Online
FORMS
Standard Dental Claim
Full Medical History
Insurance Information and Agreement
staff
Staff Covid-19 Consent Form
Staff Name
*
First
Last
Staff Email
*
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
*
Yes
No
Cough (new or worsening chronic)
Yes
No
Sore Throat
*
Yes
No
Shortness of Breath
*
Yes
No
Difficulty Breathing
*
Yes
No
Flu-like symptoms
*
Yes
No
Nausea / vomiting, diarrhea, abdominal cramps (or unknown origin)
*
Yes
No
Conjunctivitis (Pink Eye)
*
Yes
No
Decrease of loss of sense of taste or smell
*
Yes
No
Chills
*
Yes
No
Headaches
*
Yes
No
Unexplained Fatigue / Malaise / Muscle Aches
*
Yes
No
Runny nose / nasal congestion without other known cause
*
Yes
No
Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
*
Yes
No
Are you waiting for the results of a laboratory test for the novel coronavirus
*
Yes
No
Have you returned to Ontario from any country outside of Canada whether by car, air, bus or train in the past 14 days.
*
Yes
No
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.
*
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. 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 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
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