The care you seek, 6 days a week!

COVID-19 Pandemic Dental Treatment Consent Form

I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus has a long incubation period during which carries of the virus may not show symptoms and still be contagious.

I confirm that I am not presenting any of the following symptoms of COVID-19 identified by the Ontario Health Services:

OR

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above listed dental treatment completed during the COVID-19 pandemic.

Patient’s Medical History Questionnaire

Medical Alert

IN CASE OF EMERGENCY, WE SHOULD NOTIFY:

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand.

PLEASE FILL IN THE ENTIRE FORM

Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Chest pain, angina
Rheumatic fever
Pacemaker
Steroid therapy
Seizures (epilepsy)
Heart attack
Mitral valve prolapse
Lung disease
Diabetes
Kidney disease
Stroke, TIA
Tuberculosis
Stomach ulcers
Thyroid D
Shortness of breath
Heart murmur
Cancer
Arthritis
Drug/alcohol, cannabis use or dependency
Osteoporosis medications (e.g., Fosamax, Actonel)
Hepatitis A/B/C
HIV
High blood pressure
Low blood pressure
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe
Yes
No
Not sure/Maybe

PATIENT DENTAL HISTORY

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

Have you ever experienced any of the following problems your jaw:

Yes
No
Yes
No
Yes
No
Yes
No

To the best of my knowledge, the above information is correct:

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Info

Westfort Family Dental Office

124 Frederica Street E

Thunder Bay, ON P7E 3V5

Phone: 807-623-3970 

Email: info@westfortdentaloffice.com

Hours

Monday 09:00 AM - 06:00 PM

Tuesday - Saturday 09:00 AM - 05:00 PM

Sunday Closed

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Student and senior discounts are available

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