First Canadian Place, 100 King St W, Toronto, ON M5X 1C8 CA
    (Unit # CN 0121) 

COVID-19 Patient Screening

Please answer the following questions to ensure you are COVID-19 symptom free.

2. Do you have or recently have had (within 10-14 days) any of the following symptoms:

Please wear a mask to your scheduled appointment, if you do not have one will be provided.

Acknowledgement and Consent During Covid-19

• I have received information about Covid-19
• I acknowledge that I have informed the dental practice if I have ANY of these symptoms or risk factors.
• I accept that while the risk of transmission of the virus in a dental office setting is low, the risk is not zero.
• I understand that the dental treatment options may be limited during this time to reduce/eliminate the risk of transmission.
• I know I have the right to ask questions about this form and to have those questions answered to my satisfaction.
• By clicking the "submit" button you acknowledge and consent to the above and this will be used as your digital signature.

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(416) 868-1066