Covid Form

COVID-19 Pandemic Emergency Dental Treatment Consent Form

Due to the COVID-19 Pandemic we have instituted an additional emergency dental treatment consent form. Please submit the form prior to arrival.

Printable Form

COVID-19 Pandemic Emergency Dental Treatment Consent Form

Patient’s Name:
E-mail:

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

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I understand that dental procedures create water spray which is 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.

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I have been made aware of the Royal College of Dental Surgeons of Ontario’s guidelines that under the current pandemic all non-urgent dental care is not allowed. Dental visits should be limited to emergency dental treatment:

  • Oral-facial trauma
  • Cellulitis or other significant infection
  • Especially if compromising the patient’s airway prolonged bleeding
  • Pain that cannot be managed by over-the-counter medications

OR

urgent care, management and treatment of conditions that require immediate attention to relieve pain and/or risk of infection, including:

  • Severe dental pain from pulpal inflammation
  • Pericoronitis or third-molar pain
  • Surgical post-operative osteitis
  • Dry socket dressing changes
  • Abscess or localized bacterial infection resulting in localized pain and swelling tooth fracture resulting in pain
  • Pulp exposure or causing soft tissue trauma
  • Dental trauma with avulsion/luxation
  • Final crown/bridge cementation if the temporary restoration is lost
  • Broken or causing gingival irritation
  • Biopsy of a suspicious oral lesion or abnormal oral tissue
  • Replacing a temporary filling in an endodontic access opening for patients experiencing pain
  • Snipping or adjusting an orthodontic wire or appliance piercing or ulcerating the oral mucosa
  • Treatment required before critical medical procedures can be provided

I confirm I am seeking treatment for a condition that meets these criteria.

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I confirm that I am not presenting any of the following symptoms of COVOID-19 identified by Public Health Services:

  • Fever > 38°C
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  • Cough
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  • Sore Throat
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  • Shortness of Breath
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  • Difficulty Breathing
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  • Flu-like Symptons
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  • Runny Nose
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OR

I confirm that I am not currently positive for the novel coronavirus.

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I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus.

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I verify that I have not returned to Ontario from any country outside of Canada whether by car, air, bus or train in the past 14 days.

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I understand that any travel from any country outside of Canada, including travel by car, air, bus or train, significantly increases my risk of contracting and transmitting the novel coronavirus. Ontario Health Services require self-isolation for 14 days from the date a person has returned to Canada.

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I understand that Public Health has asked individuals to maintain social distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive dental treatment.

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I verify that I have not been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by Public Health, the Communicable Disease Control or any other governmental health agency.

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Signature:

Printed Name: