• Date Format: MM slash DD slash YYYY
    I understand the novel coronavirus causes the disease known as COVID-19. 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. I understand that certain dental procedures create aerosols which are one way that the novel coronavirus can spread.
    By selecting 'None of the Above' I confirm that I am NOT experiencing any of the above listed symptoms of COVID-19
    I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to work on today's date during the COVID-19 pandemic. I understand that I may revoke this consent to provide dental treatment or assist with the provision of dental treatment at any time during the day. This means that I may change my mind.