COVID-19 SAFETY UPDATE

More information on our new COVID-19 Safety Procedures can be found here:

We are opening on June 15, 2020!

Click Here For More Information COVID Treatment Consent Form

1015 Golf Links Road, Unit 401B Ancaster Ontario

Call Us

905 648-9598

Book Appointment

Your perfect smile is a click away!

Call Us

905 648-9598

Book Appointment

Your perfect smile is a click away!

COVID-19 Pandemic Dental Treatment Consent Form

Due to the COVID-19 Pandemic we have instituted an additional dental treatment consent form. Please submit the form prior to arrival.

Patient's Name:

E-mail:

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

Click to Initial

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.

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

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

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  • Fever > 38°C
  • Cough (New or Worsening)
  • Shortness of Breath
  • Difficulty Breathing
  • Sore Throat
  • Difficulty Swallowing
  • Decrease or loss of sense of taste or smell
  • Chills
  • Headaches
  • Unexplained fatigue / Malaise / Muscle Aches (myalgias)
  • Pink eye (conjunctivitis)
  • Runny nose / nasal congestion without other known cause
  • Nausea/vomiting, diarrhea, abdominal cramps (of unknown origin)

OR

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

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

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

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

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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.

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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.

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List of Dental Treatment:

Signature:

Printed Name: