COVID-19 Pandemic Dental Risk Consent

Lancaster Dental

493 Lancaster Street West, Suite #206
Kitchener, ON N2K 1L8
Phone: 519-578-9670

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Patient Name*

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Please read the patient acknowledgement below, and check off each point confirming your understanding of given point.

I understand the SARS CoV-2 virus causes the disease known as COVID-19 and that it is currently a pandemic. I understand that the SARS CoV-2 virus has an 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 Ontarians exercise caution.

I understand that oral surgery/dental procedures can create water and/or blood spray, which is one way that the SARS CoV-2 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 coronavirus.

I understand that due to the visits of other patients, the characteristics of the SARS CoV-2 virus, and the characteristics of dental procedures, I have an elevated risk of contracting the novel coronavirus simply by being in the dental office.

I agree to complete a COVID-19 screening questionnaire as required by the Ministry of Health.

If I received COVID-19 test results in the past 10 days, the last results I received were negative OR I have completed the required isolation period as indicated by public health authorities.

I confirm that I am not waiting for the results of a test for COVID-19.

I confirm that this is not currently a period during which public health authorities required me to self-isolate.

Consent

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

Patient Signature (Type Your Full Name)*

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