COVID-19 Pandemic Consent Form - Full Patient Form

This is our full COVID-19 test form. Any text can be submitted here to instruct the patient on how to fill out the form.




I understand and agree

I understand and agree

I understand and agree

I do NOT have a fever > 38°CI do NOT have a new cough or worsening chronic coughI do NOT have a sore throat or painful swallowingI do NOT have new or worsening shortness of breathI do NOT have difficulty breathingI do NOT have flu-like symptomsI do NOT have a runny noseI do NOT have Loss of smell or taste

I confirm I know that there are categories of people who are considered to be high risk. I understand the high risk category factors are being 65 years of age or older, heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder.I fall into a high risk categories and my dentist and I have discussed the risks, and I have agreed to proceed with treatment.


I understand and agree

I understand and agree

I understand and agree

I understand and agree

I understand and agree

I understand and agree


I understand and agree


SIGNATURE OF PATIENT