COVID-19 Patient Consent Form

Please enter your first name here.
Please enter your last name here.
Please enter your phone number.
Do you have, or have you had any flu-like symptoms in the last 14 days? This may include cough, shortness of breath or any two of: fever, headache, chills, sore throat, repeated shaking, new loss of taste or smell, muscle aches, nausea, fatigue, diarrhea or vomiting.
Are you awaiting results for a lab test for COVID-19?
Have you ever tested positive for a COIVD-19 test?
If you have tested positive in a COVID-19 test, when was it?
Have you or a family member been asked to self-isolate or self-quarantine in the last 14 days?
Have you had close contact with an individual who has tested positive for COVID-19 in the last 14 days?
Have you recently experienced any loss of smell or taste?
If you have travelled off of Vancouver Island or had any visitors from off of Vancouver Island in the last 14 days, please provide additional details.
Do you live with, or have you been in close contact with anyone who would answer yes to any of the above questions?
If you have had close contact with anyone who would answer yes to any of the above questions, please provide additional details.
I am aware that the current COVID-19 pandemic is an ever-changing situation. This means that Dogwood Family Dentistry Centre may change protocols as the situation dictates, in order to keep patients safe.
I understand my team at Dogwood Family Dentistry Centre is under duress to maintain the guidelines that will keep me safe. I will show patience and use kind words when I am communicating with any of the dental team.
I will tell the truth when answering the COVID-19 screening questions provided by Dogwood Family Dentistry Centre.