Please read this form and sign where indicated.
I understand there is currently a health pandemic associated with COVID-19 and the novel coronavirus
I understand public health authorities have recommended maintaining social distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance while receiving dental treatment.
I understand that oral surgery/dental procedures can create water and/or blood spray, and that there may be an elevated risk of contracting and spreading the novel coronavirus in a dental office.
I confirm that I do not have any two or more of the following symptoms of COVID-19: fever, new or worsening cough, sore throat, runny nose or headache, and that this is not currently a period where I am required to self-isolate for14 days.
I confirm that I have not tested positive for COVID-19 and that I am not currently waiting for the results of a test for COVID-19.
I hereby consent to have dental treatment completed during the COVID-19 pandemic.