Online COVID-19 Form

Although we always follow, strict safety measures in our practice to eliminate the risk of cross-contamination and spreading any Virus and Bacteria. 

Please read the consent form and sign where indicated and email it back to us before your arrival for your treatment.

Name and Family Name:  

1) I understand there is currently a health risk associated with COVID-19 and the novel coronavirus.

2) I Understand public health authorities have recommended social distancing of at least 2 meters ( 6 feet ) which is not possible to maintain this distance while receiving dental treatment.

3) I understand that oral surgery / dental procedures can create water/or blood spray and there may be an elevated risk of exposure and spreading the novel coronavirus in a dental office.

4) I Confirm that I do not have any two or more of the following symptoms of COVID-19:

-Fever, -New or worsening cough, -Sore throat, -Runny nose, or headache.

5) I Confirm that I am Not required to self -isolate for 14 days.

6) I confirm that, I have not been tested positive for COVID-19 and that I am not currently waiting for the result of a test for COVID-19.

7) I hereby consent to have dental treatment completed during the COVID-19 pandemic.

Office Location of your upcoming appointment