613-237-7177
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Proactive Oral Hygiene Care
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White Filings
Extraction
Wisdom teeth
Inlays/Onlays
Same Day Dental Crown
Replacement
Dental implants
Dental bridges
Removable partial dentures
Complete dentures
Cosmetic Dentist
Smile Makeovers
Teeth Whitening
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Cosmetic Bonding
Invisalign® Dentist
TMD
Sedation
Sleep Apnea
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Patient Acknowledgement Form
Patient Acknowledgement Form
Date / Time
*
Patient Full Name
*
Please read the patient acknowledgement below, and initial or sign in all areas indicated.
I, (initial) understand the novel corona-virus causes the disease known as COVID-19 and that it is currently a pandemic. I understand that the novel corona-virus virus 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 federal and provincial authorities have recommended that Ontarian's stay home and avoid close contact with other people when at all possible.
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I, (initial) I understand that oral surgery/dental procedures can create water and/or blood spray, which is one way that the novel corona-virus 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 corona-virus.
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I, (inital) I understand the federal and provincial authorities have asked individuals to maintain social distancing of a least two (2) meters (six (6) feet) and I recognize it i! not possible to maintain this distance while receiving dental treatment.
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I, (initial) If I received COVID-19 test results in the past three (3) months, the last results I received were negative. If applicable, approximate date of test: I confirm that I am not waiting for the results of a test for COVID-19.
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I, (initial) I understand that due to the visits of other patients, the characteristics of the novel corona-virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the novel corona-virus simply by being in the dental office. I also confirm that I do NOT have any TWO OR MORE or the following symptoms of COVID-19: (i) fever, (ii) new or worsening cough, (iii) sore throat, (iv) runny nose or (vi headache.
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I, (intial) I confirm that this is not currently a period during which public health authorities required I self-isolate for 14 days.
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I, (initial) I verify the information I have provided on this form is truthful and complete. I knowingly and willingly consent to have emergency surgical/dental treatment completed during the COVID-19 pandemic.
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Patient Signature
*
Phone
Submit
613-237-7177
Meet the Team
Dental Services
Free Consultation
Prevention & Check Ups
Proactive Oral Hygiene Care
Dental Laser
Restoration
3D CEREC Technology
Endodontics Root Canal Treatment
White Filings
Extraction
Wisdom teeth
Inlays/Onlays
Same Day Dental Crown
Replacement
Dental implants
Dental bridges
Removable partial dentures
Complete dentures
Cosmetic Dentist
Smile Makeovers
Teeth Whitening
Porcelain Veneers
Cosmetic Bonding
Invisalign® Dentist
TMD
Sedation
Sleep Apnea
Metcalfe Dental Experience
Covid-19 Screening
Book An Appointment