Covid-19 Health Declaration

COVID-19 Pandemic Dental Treatment Consent 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 the dental office.

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

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

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

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


I, the undersigned, understand that the information contained in this health declaration form are essential to the dental practices ability to provide me with safe treatment. I certify that all the information that I have completed is correct and that I have not knowingly omitted data. By initialing this digital document, I consent to the collection of my personal information via an electronic device. I agree that my initials will be legally adopted as my signature and that this form is legally binding. Additionally, I agree that my typed name and initials will act as official representatives of my personal signature.

Form Completed & Authorized by:

Thank you for submitting your health declaration.




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