Covid-19 Pandemic

Dental Treatment Consent Form

CMOH Order 05-2020 legally obligates any person who has the following: cough, fever, shortness of breath, runny nose, or sore throat (that is not related to a pre-existing illnes or health condition), to be in isolation (quarantine) for 14 days from the start of the symptoms, or until symptoms resolve, whichever takes longer. If they are exhibiting any of these symptoms, it is suggested they complete the COVID-19 Self Assessment online tool to determine if they should be tested.

I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Health Services: