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HOME
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
SERVICES
Emergency Services
Emergency Dental Exams
Dental X-Rays
Cuts & Lacerations
Dental Root Canal
Dental Filling Cavities
Crowns & Bridges
Repair Broken Teeth, Fillings, Crowns & Dentures
Replacement Of Fillings & Crowns
Removal Of Foreign Bodies
Treatment Complications
Cleaning and Prevention
Complicated Tooth Extractions
Dental Restorations
Cosmetic Dentistry
Periodontal Disease
FOR STUDENTS
BLOG
News
SERVICE AREAS
Waterloo
Beechwood Waterloo Ontario
Beechwood West-Ontario
Clair Hills-Ontario
Colonial Acres-Ontario
Upper Beechwood-Ontario
View All Areas
Book An Appointment
COVID-19 Pandemic Dental Risk Consent
COVID-19 Pandemic Dental Risk Consent
Waterloo Emergency Dental Centre
258 King Street North, Unit #7,
Waterloo, Ontario, Canada N2J 2Y9
Phone: (519) 883-0505
Today's Date
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Patient Name
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First
Middle
Last
Who is Filling Out This Form?
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Patient
Other
Please Specify
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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Date
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DD slash MM slash YYYY
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