COVID-19 Consent Form

COVID-19 CONSENT FORM

DD slash MM slash YYYY
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.
I understand that dental procedures create water and/or blood spray which is one way that the novel coronavirus can spread.
Name(Required)
Dental Office Consent(Required)
Symptoms(Required)
By selecting all, I confirm that I am not presenting any of the following symptoms of COVID-19 listed
Initials(Required)
Consent(Required)
COVID-19 Consent(Required)
COVID-19 Consent(Required)
Initials(Required)
Travel outside of Canada(Required)
Self-isolation consent(Required)
Physical distancing consent(Required)
Close Contact consent(Required)
I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.
Name(Required)

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