Covid-19 Consent Form COVID-19 Consent Form Name(Required) First Last Email(Required) Date(Required) MM slash DD slash YYYY Do you have any of the following symptoms of COVID-19?(Required)A fever higher than 38 degrees celsius, a cough, sore throat, shortness of breath, difficulty breathing, flu-like symptoms or a runny nose. (If you have any of these symptoms, we will ask that you reschedule.) Yes No Are you, or is anyone in your household, awaiting results for a COVID-19 test?(Required) Yes No Are you, or anyone in your household, currently in isolation for testing positive for COVID-19?(Required) Yes No Have you tested positive for COVID-19 in the past?(Required) Yes No Have you experienced a recent loss of taste or smell?(Required) Yes No Even if you do not have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?(Required) Yes No In the last 14 days, have you been in physical contact with any person that is currently COVID-19 positive?(Required) Yes No Do you have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?(Required) Yes No Do you have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?(Required) Yes No (Required) I knowingly and willingly consent to have emergency or standard dental treatment completed during COVID -19 pandemic(Required) I understand the novel coronavirus causes the disease known as COVID-19 and that it has a long incubation period during which carriers of the virus may not show symptoms and still be contagious(Required) I confirm that I am not currently positive for the novel coronavirus(Required) I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus(Required) I verify that I have not returned from any country outside of Canada in the past 14 days(Required) I understand that Public Health has asked individuals to maintain social distancing of at least 2 metres (6ft) and it is not possible to maintain this distance and receive dental treatment(Required) I verify that I have not been identified as a contact of someone who has tested positive for COVID-19 or been asked to self-isolate by Public HealthCAPTCHA
