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. *

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. *

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. *

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. *

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. *

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

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. *

Patient Signature *

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