Patient Acknowledgement: COVID-19 Risk | Belleville Dentistry | Dr William Hern

First Name*

Last Name*

Email Address*

Phone*

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.*

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.*

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.*

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.*

Yes I understand

I agree to complete a COVID-19 screening questionnaire as required by the Ministry of Health.*

Yes I will

If I received COVID-19 test results in the past three (3) months, the last results I received were negative.*

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.*

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.*

I confirm

I verify the information I have provided on this form is truthful and complete.*

I verify

I knowingly and willingly consent to have emergency surgical/dental treatment completed during the COVID-19 pandemic.*

I consent

Patient Acknowledgement: COVID-19 Pandemic Dental Risk