Please fill out the form before you see a dental provider for care

(the * indicates a mandatory field)

I have had the COVID-19 Vaccine over 2 weeks ago.
I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. 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. For this reason, it is recommended to stay home and avoid close contact with other people when at all possible
I understand the federal and provincial governments have asked individuals to maintain social distancing of a least 2 metres (6 feet) and I recognize it is not possible to maintain this distance while receiving dental treatment
I understand that it is possible that oral surgery/dental procedures can create water and/or blood spray, which may be 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 visits of other patients, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have an elevated risk of contracting AND SPREADING the novel coronavirus simply by being in the dental office.
I CONFIRM THAT I DO NOT HAVE: a pending or confirmed covid-19 positive test result, have been told to self-isolate, have experienced any new covid symptoms since completing the screening questionaire or other covid related issues