We provide comprehensive care to our patients.
Are you a:
PatientCaregiver / Legal Guardian / Parent
Do you or have you ever had a confirmed case of COVID-19?
Have you been tested for COVID - 19 what were the results?
(If you never tested for Covid, then write N/A)
Have you had close contact with a confirmed case of COVID-19 without PPE?
Have you traveled outside of Ontario in the past 14 days?
Do you have any of the following symptoms:
• Fever • New onset of cough • Worsening chronic cough • Shortness of breath • Difficulty breathing • Sore throat • Difficulty swallowing • Decrease or loss of sense of taste or smell • Chills • Headaches • Unexplained fatigue/malaise/muscle aches (myalgias) • Nausea/vomiting, diarrhea, abdominal pain • Pink eye (conjunctivitis) • Runny nose/nasal congestion without other known cause
Are you 70 years of age or older, experiencing any of the following
symptoms: delirium, unexplained or increased number of falls,
acute functional decline, or worsening of chronic conditions?
I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a
pandemic. I understand that 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, I understand that the federal
and provincial authorities have recommended that Ontarians stay home and avoid close contact with
other people when at all possible. Initials
I confirm that I am not waiting for the results of a test for COVID-19. Initials
I verify the information I have provided on this form is truthful and complete. I knowingly and willingly
consent to have emergency surgical/dental treatment completed during the COVID-19 pandemic.
Please Click Twice to submit the form.
326 Queens Ave London, ON N6B 1X4
Phone: (519) 439-6491