COVID-19 Patient Pre-Screening Form

1400 Cornwall Rd., Unit 1, Oakville, ON, L6J 0B2      905-842-5051

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

PLEASE BRING YOUR OWN MASK OR FACE COVERING. YOU WILL BE ASKED TO USE OUR HAND SANITIZER UPON ENTERING AND LEAVING THE OFFICE.

Personal Information

Patient's Name:
Patient's 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.

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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.

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I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Public Health Services:

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  • Fever > 38°C
  • Cough (new or worsening chronic)
  • Sore Throat
  • Shortness of Breath
  • Difficulty Breathing
  • Flu-like Symptoms
  • Runny Nose
  • Conjunctivitis (Pink Eye)
  • Decrease or loss of sense of taste or smell
  • Chills
  • Headaches
  • Unexplained Fatigue / malaise / muscle aches
  • Nausea/vomiting, diarrhea,abdominal pain
  • Difficulty swallowing

OR

I confirm that I am not currently positive for the novel coronavirus.

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I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus.

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I verify that I have not returned to Ontario from any country outside of Canada whether by car, air, bus or train in the past 14 days.

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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. Ontario Health Services require self-isolation for 14 days from the date a person has returned to Canada.

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

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I verify that I have not 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.

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Signature