COVID-19

Screening and Treatment Consent Form

Patient Name*

First Last

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 due to the frequency of visits of other denturist patients, the characteristics of the novel coronavirus, and the characteristics of denture procedures, that I have an elevated risk of contracting the novel coronavirus simply by being in a denturist office.

I have a fever greater than 38°C / 100°F*

Yes
No

I have a new cough*

Yes
No

I have shortness of breath*

Yes
No

I have flu-like symptoms*

Yes
No

I have tested positive for the novel coronavirus*

Yes
No

I tested positive on this date*

I have since been confirmed negative*

Yes
No

I was confirmed negative on this date*

I was confirmed negative by*

Swab test
Blood test
Doctor

I am currently waiting for the results of a laboratory test for the novel coronavirus.*

Yes
No

I have been outside the country in the past 14 days.*

Yes
No

I have diabetes*

Yes
No

I have respiratory problems*

Yes
No

I have an autoimmune disorder*

Yes
No

I would like to report other conditions

Consent*

I understand it is recommended to maintain social distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive denture treatment.*

Consent*

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 any governmental health agency.*

Consent*

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

Patient Signature*

Email

This field is for validation purposes and should be left unchanged.