Risk Acknowledgement Form

COVID-19 Safety Protocol – Risk Acknowledgement Form

The safety of our patients and our dental team is paramount to us at Downtown Abbotsford Dental. This is reflected in our office’s enhanced infection control protocols, use of the appropriate PPE and detailed patient screen form. We thank you for taking the time to complete this questionnaire which helps us to reduce the risk for everyone who comes through our doors.

RISK ACKNOWLEDGEMENT FORM:

Please read the patient acknowledgement questions and check all areas indicated.

Patient Name *

First

Last

I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. 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. For this reason, it is recommended to stay home and avoid close contact with other people when at all possible. *

• I Agree

I understand the federal and provincial governments have asked individuals to maintain social distancing of a least 2 metres (6 feet) and I recognize it is not possible to maintain this distance while receiving dental treatment. *

• I Agree

I understand that it is possible that oral surgery/dental procedures can create water and/or blood spray, which may be 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. *

• I Agree

I understand that due to the visits of other patients, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have an elevated risk of contracting AND SPREADING the novel coronavirus simply by being in the dental office. *

• I Agree

I understand that patients considered high risk for severe Covid-19 include those with pre-existing conditions such as serious respiratory disease, serious heart conditions, immunocompromised conditions, severe obesity, diabetes, chronic kidney disease or those undergoing dialysis, liver disease; pregnant patients and patients who are 70 years and over. These patients should defer unnecessary dental treatments.

• I have 1 or more of the above conditions
• I request a review of my conditions
• I am over the age of 70
• I do not have any of the pre-existing conditions listed above

Specify your condition.

I verify I have read the information and understand the risks. *

• I Agree

Date *

Phone

Submit

All of us at Downtown Abbotsford Dental look forward to seeing you soon, please arrive five minutes before your scheduled appointment. Office protocols require all persons to wear a mask upon entry into the office.

If You Have Any Questions Or Concerns Please Telephone: 604-850-1617