ACME Dental - Covid-19 Consent Form

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 meters (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 have been advised that patients considered high risk for severe COVID-19 include those with pre-existing conditions such as serious respiratory disease, serious heart conditions, immunocompromised conditions, severe obesity, diabetes, chronic kidney disease or those undergoing dialysis, and liver disease; pregnant patients; and patients who are 70 years and over. I have been advised that if I am considered high risk that my treatment should be deferred whenever possible.

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.

Aerosol Generating Procedures (AGPs)

Dental aerosols are generated with many procedures, as shown in Table 1. Aerosols that may contain Corona virus from an infected patient occur when saliva is aerosolized along with products of the procedure. This occurs with aerosol procedures, from the use of certain dental and hygiene instruments, where the saliva cannot be prevented from entering the procedure area and becoming aerosolized. If these procedures are required, they must be performed with measures to mitigate the impact of aerosols.

For many procedures, potentially infectious aerosols may be minimized with the following steps:

When the above steps are followed, and the treatment proceeds with use of high-speed instruments and other aerosolizing procedures, the aerosols created will only contain tooth debris and no infectious saliva, minimizing the risk of infectious aerosols. Using HVE will minimize risk of infectious aerosols and is expected to be suitable for patients in the low risk category for COVID-19. Research is currently underway to quantify the risks of this approach.

Ultrasonic and Sonic Scalers	Considered the greatest source of aerosol contamination; use of a high-volume evacuator will reduce the airborne contamination by more than 95%
Air-Water Syringe	Bacterial counts indicate that airborne contamination is nearly equal to that of ultra-sonic scalers; high-volume evacuator will reduce airborne bacteria by nearly 99%
Tooth Preparation with High Speed Handpiece	Minimal airborne contamination if a rubber dam is used
Tooth Preparation with Air Abrasion	Bacterial contamination is unknown; extensive contamination with abrasive particles has been shown

Note this website is for demonstration purposes only

Aerosol Generating Procedures (AGPs)

Patient Information

I have reviewed the privacy consent policy (click here to review).*