DrB Dental Covid-19 Symptoms and Acknowledgement of Risk

Are you experiencing cold, flu or COVID-19-like symptoms, even mild ones (symptoms include: fever and/or chills, cough, sore throat and/or painful swallowing, stuffy and/or runny nose, loss of sense of smell, headache, body/muscle aches, loss of appetite, diarrhea, nausea and/or vomiting)? *
I acknowledge that I must bring a mask and wear it when entering, sitting in the waiting room, and walking around the dental office. *

If you have any concerns and/or questions, do not hesitate to contact us.

Please read the following statements

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

I understand the federal and provincial governments have asked individuals to maintain social distancing of a least 2 metres (6 feet) and I recognize it is not possible to maintain this distance while receiving dental treatment.

I understand that it is possible that oral surgery/dental procedures can create water and/or blood spray, which may be 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.

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 and spreading the novel coronavirus simply by being in the dental office.

I understand extra measures have been put in place to prevent the spread of all pathogens, including, but not limited to, wearing personal protective equipment (staff and patients), enhanced suction during treatment to limit aerosols, frequent sanitation of surfaces, and enhanced ventilation.

By signing below, I confirm I have read and agree to having my dental treatment completed. 

Signature *