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
Q1: Are you immuno-compromised?
YesNo



Q2: Do you have any of these symptoms? Are these symptoms new, worsening and not related to other known causes of conditions2?
YesNo


  • Fever and/or chills
  • Cough or barking cough
  • Shortness of breath
  • Decrease or loss of taste or smell
  • Muscle aches/joint pain
  • Extreme tiredness
  • Sore throat
  • Runny or stuffy/congested nose
  • Headache
  • Nausea, vomiting and/or diarrhea
  • Abdominal pain
  • Pink eye



Q3: Have you been told (by a doctor, health care provider, public health unite, federal border agent, or other government authority) that you should currently be a quarantining, isolating or staying at home?
YesNo



Q4: In the last 10 days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self-testing kit?
YesNo


PLEASE NOTE: If you answered "yes" to any question above, please speak to our front desk.


SIGNATURE OF PATIENT
Printed Name
Date
(YYYY-MM-DD)