Have you travelled outside of Canada in the past 14 days? *

Yes

No

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

Yes

No

Do you have any of the following symptoms? *

Fever New onset of cough Worsening chronic cough Shortness of breath Difficulty breathing Sore throat Difficulty swallowing Decreas or loss of sense of taste or smell Chills Headaches Unexplained fatigue/malaise/muscle aches (myalgias) Nausea/Vomiting, diarrhea, abdominal pain Pink eye (conjunctivitis) Runny nose/nasal congestion without other known cause

Yes

No

If you are 70 years of age or older, are you experiencing any of the following symptoms of delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?

Yes

No

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

I agree

I understand the federal and provincial authorities have asked individuals to maintain social distancing of at least 2 m (6 ft.) and I recognize it is not possible to maintain this distance while receiving dental treatment. *

I agree

I understand that oral surgery/dental procedures can create water and/or blood spray, which is one way that the novel coronavirus can spread. I understand that the ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus. *

I agree

I understand that due to the visits of other patient, 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 the the oral surgery/dental office. *

I agree

I agree to complete a COVID-19 screening questionnaire as required by the Ministry of Health. *

I agree

If I received COVID-19 test results in the past three (3) months, the last results I received were negative. *

I agree

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

I agree

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

I agree

I verify the information I have provided on this form is truthful an complete. I knowingly and willingly consent to have emergency surgical/dental treatment completed during the COVID-19 pandemic. *

I agree

NAME OF PATIENT, PARENT, or GUARDIAN *

First Name

Last Name