Patient Acknowledgement Form COVID 19

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Please complete this form upon arriving at Mission Creek Dental and show your score to reception staff.

Option 1

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Your First and Last Name *

Your Email Address *

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. *

1 point

Yes

Required

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. *

1 point

Yes

Required

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. *

1 point

Yes

Required

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. *

1 point

Yes

Required

I confirm that I do NOT have any TWO OR MORE or the following symptoms of COVID-19: fever, new or worsening cough, sore throat, runny nose or headache(Initials)I confirm that I have not tested positive for COVID-19. *

1 point

Yes

Required

I confirm that I am not waiting for the results of a test for COVID-19. *

1 point

Yes

Required

I confirm that this is not currently a period where I required to self-isolate for 14 days. *

1 point

Yes

Required

I verify the information I have provided on this questionnaire is truthful and accurate. I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic. *

1 point

Yes

Required

Please View your score and show your screen to reception staff.

Adapted from Dental Association of PEI COVID-19 Pandemic Emergency Dental Risk Acknowledge by Patient & British Columbia Dental Association. Copyright © 2020 All rights reserved. www.missioncreekdental.com

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