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Home
Services
For New Parents
Need a tooth pulled.. Now what?
Budgeting Teeth Replacement
Least Expensive
More Expensive
Most Expensive
Implant Complications
CariVu™
Check Ups and Cleaning
ClearCorrect Alignment
Crown
Crown Lengthening
From the Hygienist
Night Guards
Oral Cancer Screening
VELscope®
Identafi®
Orthodontics
Painless Dental Anesthesia
Pinhole Surgery For Receding Gums
Root Canals
Sedation Options
Snoring and Apnea
Teeth Whitening
White Fillings
About Us
See the Office Tour!
Dr. Paul
Dr. Yazdi
Staff
Client Interviews
Testimonials
Resources
COVID Forms and FAQs
News and Alerts
Dental Trauma
Filling Materials
Orthodontic Care
Links
Contact Us
Home
Services
For New Parents
Need a tooth pulled.. Now what?
Budgeting Teeth Replacement
Least Expensive
More Expensive
Most Expensive
Implant Complications
CariVu™
Check Ups and Cleaning
ClearCorrect Alignment
Crown
Crown Lengthening
From the Hygienist
Night Guards
Oral Cancer Screening
VELscope®
Identafi®
Orthodontics
Painless Dental Anesthesia
Pinhole Surgery For Receding Gums
Root Canals
Sedation Options
Snoring and Apnea
Teeth Whitening
White Fillings
About Us
See the Office Tour!
Dr. Paul
Dr. Yazdi
Staff
Client Interviews
Testimonials
Resources
COVID Forms and FAQs
News and Alerts
Dental Trauma
Filling Materials
Orthodontic Care
Links
Contact Us
Patient Acknowledgement: COVID-19 Pandemic Dental Risk
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First Name
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Last Name
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Email Address
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Please read the patient acknowledgement below, and select the Check box beside each statement indicating you have read and understand all areas indicated.
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. For this reason, I understand that the federal and provincial authorities have recommended that Ontarians stay home and avoid close contact with other people when at all possible.
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Yes I understand
I understand the federal and provincial authorities have asked individuals to maintain social distancing of a least two (2) meters (six (6) feet) and I recognize it is not possible to maintain this distance while receiving dental treatment.
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Yes I understand
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.
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Yes I understand
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.
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Yes I understand
I agree to complete a COVID-19 screening questionnaire as required by the Ministry of Health.
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Yes I understand
If I received COVID-19 test results in the past three (3) months, the last results I received were negative.
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Yes negative
No tests in the past 3 months
If applicable, approximate date of last test:
I confirm that I am not waiting for the results of a test for COVID-19.
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I am not awaiting COVID-19 test Results
I confirm that this is not currently a period during which public health authorities required I self-isolate for 14 days.
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I confirm
I verify the information I have provided on this form is truthful and complete.
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I verify
I knowingly and willingly consent to have emergency surgical/dental treatment completed during the COVID-19 pandemic.
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I consent
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