COVID Patient Acknowledgement Newton - Surrey Dentist | Green Apple Dental

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Patient Acknowledgement Form: COVID19 Pandemic Emergency Dental Risk

Please carefully read each consent item below and initial the box to verify you agree and understand. If you do not agree to an item or if you have any questions, please contact our office for additional information.

1. General Consent

I understand there is currently a health pandemic associated with COVID-19 and the novel coronavirus.

1. Initial

2. Social Distancing

I understand public health authorities have recommended maintaining social distancing of a least 2 metres (6 feet) and it is not possible to maintain this distance while receiving dental treatment.

2. Initial

3. Additional Consent

I understand that oral surgery/dental procedures can create water and/or blood spray, and that there may be an elevated risk of contracting and spreading the novel coronavirus in a dental office.

3. Initial

4. Symptoms Consent

I confirm that I do not have any two or more of the following symptoms of COVID-19: fever, new or worsening cough, sore throat, runny nose or headache, and that this is not currently a period where I am required to self-isolate for 14 days.

4. Initial

5. Testing Consent

I confirm that I have not tested positive for COVID-19 and that I am not currently waiting for the results of a test for COVID-19.

5. Initial

6. Treatment Consent

I hereby consent to have dental treatment completed during the COVID-19 pandemic.

6. Initial

Patient SignatureBy initialing each box above and typing out your name below you acknowledge that you understand the risks affiliated with visiting the dentist during a pandemic and acknowledge that you will adhere to all of our office rules and that you are not experiencing any symptoms and are not required to be quarantined.

Date

Adapted from Dental Association of PEI COVID-19 Pandemic Emergency Dental Risk Acknowledge by Patient

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