I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand that 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 the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand that 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 and accept the risks. I understand and do not accept the risks.

I understand the federal and provincial authorities have asked individuals to maintain physical distancing of two meters/six feet, and I recognize it is not possible to maintain distance while receiving dental treatment. I understand the federal and provincial authorities have asked individuals to maintain physical distancing of two meters/six feet, and I recognize it is not possible to maintain distance while receiving dental treatment. I understand and accept the risks. I understand and do not accept the risks.

I understand that oral surgery/dental procedures can create water and/or blood spray, which is one way that the novel coronavirus 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 oral surgery/dental procedures can create water and/or blood spray, which is one way that the novel coronavirus 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 and accept the risks. I understand and do not accept the risks.

I understand that due to the visits of other 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 the dental office. I understand that due to the visits of other 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 the dental office. I understand accept the risks. I understand and do not accept the risks.

I confirm that I do NOT have any TWO OR MORE of the following symptoms of COVID-19. (1) fever, (ii) new or worsening cough, (iii) sore throat, (iv) runny nose, or (v) headache. I confirm that this is not currently a period during which public health authorities required I self-isolate for 14 days. I confirm that I do NOT have any TWO OR MORE of the following symptoms of COVID-19. (1) fever, (ii) new or worsening cough, (iii) sore throat, (iv) runny nose, or (v) headache. I confirm that this is not currently a period during which public health authorities required I self-isolate for 14 days. I do not have two or more symptoms. I have two or more symptoms.

I confirm that this is not currently a period during which public health authorities required I self-isolate for 14 days. I confirm that this is not currently a period during which public health authorities required I self-isolate for 14 days. I have not been advised to self-isolate. I have been advised to self-isolate.

I confirm that I am not waiting for the results of a test for COVID-19. I confirm that I am not waiting for the results of a test for COVID-19. No, I am not awaiting COVID-19 test results. Yes, I am awaiting COVID-19 test results.

If I received COVID-19 test results in the past three months, the last results I received were negative. If I received COVID-19 test results in the past three months, the last results I received were negative. My COVID-19 test results were negative. My COVID-19 test results were positive. I have NOT had a COVID-19 test in the past three months.

I verify the information I have provided on this form is truthful and complete. I knowingly and willingly consent to have my dental treatment completed during the COVID-19 pandemic. I verify the information I have provided on this form is truthful and complete. I knowingly and willingly consent to have my dental treatment completed during the COVID-19 pandemic. Yes, I consent No, I do not consent

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