Patient Info

COVID -19 Patient procedure.  

As part of your pre appointment screening, this form MUST be completed before your appointment. Please contact us if you have any questions. We ask you to  to wear a mask to your appointment to help keep others safe around you (we will have masks available for those who do not have one) Please review our full COVID-19 Safety Plan before you arrive for your appointment.

Please read the patient acknowledgement below, and initial or sign in all areas indicated. 

Covid-19


  • I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. 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. For this reason, it is recommended to stay home and avoid close contact with other people when at all possible

  • I understand the federal and provincial governments have asked individuals to maintain social distancing of a least 2 metres (6 feet) and I recognize it is not possible to maintain this distance while receiving dental treatment.

  • I understand that it is possible that oral surgery/dental procedures can create water and/or blood spray, which may be one way that the novel coronavirus can spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus.

  • I understand that due to the visits of other patients, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have an elevated risk of contracting AND SPREADING the novel coronavirus simply by being in the dental office.

  • I confirm that I do NOT have any TWO OR MORE of the following symptoms of COVID-19: fever, new or worsening cough, sore throat, runny nose or headache.

  • I confirm that I have not tested positive for COVID-19.

  • I confirm that I am not waiting for the results of a test for COVID-19.

  • I confirm that this is not currently a period where I required to self-isolate for 14 days.

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

WE WILL NOT BE TREATING ANY PATIENT THAT HAS INCREASED RISK FOR COVID-19 INFECTION IN KEYSTONE DENTAL

Thank you for your patience during this changing time. This is new to our entire team and we appreciate your cooperation.  Please expect rules to be fluid as we adjust to changes and adapting to what may or may not work.