Have you been to Pearlee Dental before? *
YesNo

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. *
Agree

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. *
Agree

Are you presenting any of the following symptoms of COVID-19 identified by Public Health Services?

Fever > 38°C *
YesNo

Cough (new or worsening chronic) *
YesNo

Sore Throat *
YesNo

Shortness of Breath *
YesNo

Difficulty Breathing *
YesNo

Flu-like symptoms *
YesNo

Nausea / vomiting, diarrhea, abdominal cramps (or unknown origin) *
YesNo

Conjunctivitis (Pink Eye) *
YesNo

Decrease of loss of sense of taste or smell *
YesNo

Chills *
YesNo

Headaches *
YesNo

Unexplained Fatigue / Malaise / Muscle Aches *
YesNo

Runny nose / nasal congestion without other known cause *
YesNo

Have you tested positive for COVID-19 OR had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? *
YesNo

Are you waiting for the results of a laboratory test for the novel coronavirus? *
YesNo

Have you returned to Ontario from any country outside of Canada whether by car, air, bus or train in the past 14 days? *
YesNo

Have you been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by Public Health, the Communicable Disease Control or any other governmental health agency? *
YesNo

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. Public Health requires self-isolation for 14 days from the date a person has returned to Canada. *
Agree

I understand that Public Health has asked individuals to maintain physical distancing of at least 2 meters (6 feet) and it is not possible to maintain this distance and receive dental treatment. *
Agree

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