I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel
virus has a long incubation period during which carriers of the virus may not show symptoms and still be
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 have been made aware of the Provincial Dental Association and College guidelines that under the
current pandemic all non-urgent dental care is not allowed. Dental visits should be limited to the
treatment of ongoing tissue bleeding, alleviate severe pain or infection or conditions that
significantly inhibit normal operation of teeth and mouth, and issues that may cause anything listed
above within the next 3 to 6 months.
I confirm I am seeking treatment for a condition that meets these criteria.
I confirm that I am not presenting any of the following symptoms of COVID-19 identified by
Provincial Health Services:
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
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
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
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