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:
SYMPTOMS:


YesNo
Has the patient had a fever greater than 37.5 C in the past 14 days?
YesNo
Does the patient have or has the patient had a cough, sore throat, shortness of breath, or difficulty breathing in the last 7 days?
YesNo
Does the patient have any FLU-LIKE SYMPTOMS? (Chills, fatigue, Muscle pain or headaches.)
YesNo
Pink eye, runny nose
YesNo
Does the patient have any loss of your senses of taste or smell?
YesNo
Has the patient tested positive for COVID-19?
YesNo
In the past 14 days, has the patient been in CONTACT with anyone that is showing any symptoms of COVID-19 or has been diagnosed with COVID-19?
YesNo
IN the last 30 days, has the patient been outside of Canada?
YesNo
If outside of canada, has the patient completed the mandatory 14-days self-isolation?
SIGNATURE OF PATIENT
Printed Name
Date
(YYYY-MM-DD)