COVID-19 Form | R-Dentists Clinic

I, _________________, knowingly and willingly consent to having dental treatment during the COVID-19 pandemic.
I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not give the current limits in virus testing.
• I have been made aware of CDC guidelines of rendering treatment during the current pandemic. ___________ (Initial).
I am aware that my fever will be checked.
I am aware that social distancing is not possible with dentistry. ___________ (Initial)
I confirm that I am not presenting any of the following symptoms of COVID-19 listed below:
Fever/ Shortness of Breath
Dry Cough
Runny Nose
Sore Throat
Loss of smell/taste
I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus.___________ (Initial)
I verify that I have not traveled outside of Canada in the past 14 days. ___________ (Initial)
I verify that I have not traveled domestically within Canada by commercial airline, bus, or train within the past 14 days. __________(Initial)
Name
Date
Date Format: MM slash DD slash YYYY
Signature

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