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

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.

I understand that due to the frequency of visits of other dental 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 a dental office.

I have been made aware of the Provincial Dental Association and College guidelines that under the current pandemic all elective dental care is not recommended. Dental visits should be limited to emergency and urgent dental treatments.

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

I confirm that I am not presenting any of the following symptoms of COVOID-19:
. Fever > 38°C . Sore Throat . Flu-like symptoms . Cough . Shortness of Breath

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

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

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

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. Provincial Health Services require self-isolation for 14 days from the date a person has returned to Canada.

I understand that Provincial Health Services has asked individuals to maintain social distancing of at least 2 meters and it is not possible to maintain this distance and receive dental treatment.

I verify that I have not been in contact of someone who has tested positive for COVID19 or been asked to self-isolate by Provincial Health, The Communicable Disease Control or other governmental health agency.

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above listed emergency dental treatment completed during the COVID-19 pandemic.