About our clinic
Complete Dental Assessments
Root Canal Therapy
Laser Gum Therapy
Preventative & Gum Treatments
TMJ (TMD) Therapy
Snoring & Sleep Apnea
Migraine Pain Prevention
Book an Appointment
New Patient Form
Covid-19 Patient Consent Form
Covid-19 General Info
Date / Time
Patient Full Name
Please read the patient acknowledgement below, and initial or sign in all areas indicated.
Have you had close contact with anyone with acute respiratory illness or traveled outside of Canada in the past 14 Days?
Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?
Do you have any of the following symptoms: Fever, New Onset Cough, Worsening Chronic Cough, Shortness Of Breath, Sore Throat, Difficulty Swallowing, Decrease Or Loss Of Sense Of Taste Or Smell, Chills, Headaches, Unexplained Fatigue - Malaise - Muscle Aches, Nausea, Vomiting, Diarrhea, Abdominal Pain, Pink Eye, Running Nose, Nasal Congestion Without Other Known Cause?
Are you 70 years of age and experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?
Any "Yes" responses must be discussed with the managing dentist prior to your appointment.
I, (initial) I verify the information I have provided on this form is truthful and complete. I knowingly and willingly consent to have emergency surgical/dental treatment completed during the COVID-19 pandemic.