My Kid's Dentist

COVID-19 Patient Dental Treatment Consent Form

478 Dundas St West, Unit #9, Oakville, ON, L6H 6Y32      905-257-4377

Name of Parent / Guardian:
E-mail:
Name of Child / Patient:
The Royal College of Dental Surgeons of Ontario, Canadian Dental Association, Ontario Dental Association, Chief Medical Officer of Health an the Government of Ontario have jointly issued guidelines for routine dental care during this pandemic. My Kid’s Dentist have adopted and implemented said guidelines. In fact, My Kid’s Dentist has taken additional measures (beyond recommended guidelines) to reduce the risk of transmission within our clinics even further.

I knowingly and willingly consent to have dental treatment completed on my child during the COVID-19 pandemic. I understand that despite due diligence and all precautions taken by My Kid’s Dentist, the risk of acquiring or transmitting the disease is still present in the dental environment.

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I confirm that I and my child are not presenting with any of the following symptoms of COVID-19 such as Fever, Shortness of Breath, Difficulty Breathing, Flu-like Symptoms, Dry Cough, Runny Nose, Sore Throat, Conjuctivitis (pink eye), Decrease or loss of sense of smell/taste, Chills, Headaches, Malaise/Muscle Aches, Nausea Vomiting, Diarrhea, Abdominal Pain, &/or Difficulty Swallowing.

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I understand that My Kid’s Dentist have taken reasonable, standardized and universal measures to prevent/limit the transmission diseases blood-borne,fluid-borne or airborne). However, due to the nature of the COVID-19 virus, My Kid’s Dentist cannot guarantee that the risk of transmission is zero/non-existent.

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I understand that the recommendation of social distancing of at least 2 meters is not possible while within the dental clinic.

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