Thank you for scheduling your appointment with York Mills Orthodontics. We look forward to seeing you!
In order for us to see you in our office, you are required to complete this form no sooner than the morning of your appointment.
Please carefully review the questionnaire below and answer each question accurately. Once completed, please sign at the bottom and push SUBMIT. Thank you for helping us to ensure the health and safety of our patients, staff and the community.
COVID-19 Pandemic Dental Treatment Consent Form
Patient First Name:
Patient Last Name:



Q1: Did you receive your final (or second) vaccination dose more than 14 days ago?
YesNo
Q2: Do you have any of the following symptoms:


YesNo
Fever
YesNo
New onset of cough or worsening of chronic cough
YesNo
Shortness of breath
YesNo
Decrease or loss of sense of taste or smell
YesNo
If adult > 18 years of age: unexplained fatigue/lethargy/malaise/muscle aches (myalgais)
YesNo
If child < 18 years of age: nausea/vomiting, diarrhea



Q3: Have you tested positive for COVID 19 in the past 10 days or have you been told to isolate?
YesNo


PLEASE NOTE: Questions 4 and 5 are to be answered only if you are NOT fully immunized.


Q4: Did you travel outside of Canada in the past 14 days?
YesNo
Q5: Have you had close contact with a confirmed case of COVID 19 without wearing appropriate PPE?
YesNo
SIGNATURE OF PATIENT
Printed Name
Date
(YYYY-MM-DD)