NOTICE TO OUR PATIENTS REGARDING THE NOVEL CORONAVIRUS (COVID-19)

Salvaggio Dentistry continues to actively monitor the current situation regarding the spread of COVID-19 in the Greater Toronto Area by following guidelines and recommendations from Public Health Agencies. We are doing everything to ensure the health and safety of our members and staff.

New Updates to our Patient Policies:

If you have recently travelled anywhere, have any signs of cold or flu-like symptoms, or have been in contact with someone exhibiting symptoms, please self-isolate and do not visit the dental office for 14 days for precautionary reasons.
All patients will now be required to sign-in and complete a mandatory Declaration Form prior to accepting treatment.

COVID-19 SCREENING FORM

I understand the novel coronavirus causes the disease known as COVID-19. 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.

I understand that dental procedures create water spray which is 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 frequency of visits of other dental patients, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have an elevated risk of contracting the novel coronavirus simply by being in a dental office.

I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Provincial Health Services:

Fever > 38°C

Cough

Sore Throat

Shortness of Breath

Flu-like symptoms

Chills

Repeated Shaking

Fatigue

Muscle Aches

Vomiting

Headache

New loss of taste/smell

Malaise(a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify)

Nausea

Diarrhea

I confirm that I am not currently positive for the novel coronavirus.

I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus.

I confirm that I or anyone that I live with, have not come in contact with anyone who is currently being tested for COVID-19, or has tested positive for COVID-19 within the past 14 days

I verify that I have not returned to Provincial from any country outside of Canada whether by car, air, bus or train in the past 14 days.

I understand that any travel from any country outside of Canada, including travel by car, air, bus or train, significantly increases my risk of contracting and transmitting the novel coronavirus. Provincial Health Services require self-isolation for 14 days from the date a person has returned to Canada.

I confirm that I have not travelled anywhere outside of the province within the last 14 days.

I confirm that I myself nor any family members that I live with have not been asked to self isolate or self quarantine for 14 days.

I understand that Provincial Health Services has asked individuals to maintain social distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive dental treatment.

I verify that I have not been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by Provincial Health, the Communicable Disease Control or any other governmental health agency.

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

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Last Name

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