West Kelowna Dentist | Insurance Form

Patient Name*

First Last

I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand the novel coronavirus 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.*

Yes
No

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

Yes
No

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.*

Yes
No

I understand that due to the visits of other patients, the characterists 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.*

Yes
No

I cornfirm 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.*

Yes
No

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

Yes
No

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

Yes
No

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

Yes
No

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.*

Yes
No

Signature of patient*

Date

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