Coldwater Dental Office: COVID-19 Screening Questions & Treatment Consent
To our patients:

Thank you for your support and patience in the past weeks as our office has been closed due to the COVID-19 pandemic. We are very much looking forward to resuming dental and oral care in the safest possible way for both patients and staff. Part of that initiative includes the attached COVID-19 Screening Questions and Treatment Consent that we request to be returned prior to EACH APPOINTMENT. Please call or email the office if you have any questions. Thank you.
Email address *
Today's Date *
Patient Name *
Did you have close contact with anyone with acute respiratory Illness or travelled outside of Ontario 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 (Over 38'C)
New onset of Cough or worsening chronic cough
Shortness of Breath/Difficulty Breathing
Sore throat/difficulty swallowing
Loss of taste or smell
Any other flu-like symptoms, such as gastrointestinal upset, nausea/vomiting, diarrhea, headache or fatigue/muscle aches?
Pink eye (conjunctivitis)
Runny nose/nasal congestion without other known cause
If you are 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions? (If you are NOT 70 years of ages or older, please check NO.) *
If the answer is yes to ANY of the previous questions, I understand I will be asked to reschedule today's appointment. *
Treatment Consent: Please be assured that our office has always met or exceeded the requirements set forth for sterilization and infection control from the RCDSO and PHO, and will continue to do so. However, it is possible to contract COVID-19 infection (or any other communicable disease) in any public space. Our office will provide for socially distant appointment scheduling, and also has added a number of new technologies and techniques to the practice to enhance our level of safety. However, due to the nature of the dental treatment, social distance is not possible between the patient and clinical staff/doctor. Exposure to communicable diseases is unlikely but possible. Clicking "yes" below indicates that the risks involved are accepted, and that consent is given for treatment to be provided by the office of Dr. Hiroshi Takagi and staff.
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