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

(the * indicates a mandatory field)

Have you had the VACCINE (2-3 shots) for covid-19 over 2 weeks ago?
Are you aware there it is currently a pandemic and 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
Do you understand the federal and provincial governments have asked individuals to maintain social distancing (2 metres / 6 ft) and recognize it is not possible to do this during dental treatment?
Do you understand oral surgery/dental procedures can create water and/or blood spray, which can be one way the novel coronavirus can spread. The ultra-fine nature of the aerosols can linger in the air fowhich 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

Thank you, Your Dental Care Provider will be right out!

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