Covid-19 Patient Consent Form - Blundell Orthodontics

COVID-19 PATIENT CONSENT FOR CARE FORM

Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19 also known as "Coronavirus", at any time or in any place. Be assured that we have always followed provincial regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so.

Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our clinic, just as you might be at your gym, grocery store or favourite restaurant.

"Social Distancing" has reduced the transmission of the Coronavirus. Although we have taken measures to provide distancing within our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, orthodontist, orthodontic staff and sometimes other patients at all times.

Please complete the form below and press submit.

Do you have any of the following COVID 19 symptoms: Fever, Chills, Cough, Shortness of breath, Sore throat, Painful swallowing, Runny nose, Nasal congestion, Loss of sense of smell, Headache, Muscle aches, Fatigue, Loss of appetite(Required)

Yes

Have you been in contact with anyone who has confirmed Covid-19 or has been exposed to Covid-19 within the last 14 days?(Required)

Yes

Have you travelled to any countries outside Canada (including the United States) within the last 14 days?(Required)

Yes

Although exposure to COVID-19 is unlikely, do you accept the risk and consent to treatment?(Required)

Yes

Name of Responsible Party(Required)

First Last

Patient Name (if different than above)

First Last

Date

Time

Email(Required)

Digital Signature(Required)

Please type your name

COVID-19 PATIENT CONSENT FOR CARE FORM

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