Patient’s Name:

E-mail:

I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

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.

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

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

I confirm that I am not in a high risk category including: diabetes, cardiovascular disease, hypertension, lung diseases, including moderate to severe asthma, being immunocompromised, having active malignancy or over the age of 70.

I fall into the following high risk category and my dentist and I have discussed the risks, and I agree to proceed with the treatment.

Describe Risk Category

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

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

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

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

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.

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.

I verify the information I have provided in this form is truthful and accurate. I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.

Signature:

Printed Name:

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Patient Treatment Consent Form

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