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HOME
ABOUT
Reviews
PROCEDURES
Cleanings & Prevention
Dental Exams & Cleanings
Dental X-Rays
Digital X-Rays
Fluoride Treatment
Home Care
Brushing and Flossing – A Simple Guide
Oral Hygiene Aids
Dental Sealants – What You Need to Know
Dental Restorations
Composite Fillings
Root Canal Therapy
Crowns (Caps)
Fixed Bridges
Inlay Restorations
Onlay Restorations
Dentures & Partial Dentures
Cosmetic Dentistry
Porcelain Crowns (Caps)
Porcelain Fixed Bridges
Porcelain Inlays
Porcelain Onlays
Porcelain Veneers
Tooth Whitening
Venus Teeth Whitening
Periodontal Disease
What is Periodontal (Gum) Disease?
Diagnosis
Treatment
Maintenance
Invisalign
Sedation Dentistry
PATIENT CENTRE
Patient Forms
New Patient Form
Medical History Update
5 Year Medical History Update
Covid-19 Patient Screening Form
COVID-19 Pandemic Dental Risk Consent
Testimonials
FAQs
BLOG
News
SERVICE AREAS
Kitchener Ontario
Alpine Ontario
Bridgeport Ontario
Brigadoon Ontario
Centreville Ontario
Country Hills Ontario
View All Areas
BOOK AN APPOINTMENT
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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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.
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