Coldwater Dental Office: COVID-19 Screening Questions & Treatment Consent
To our patients:

Thank you for your support and patience during the COVID-19 pandemic. We would like to provide you with the dental and oral care in the safest possible way for you, your family and our staff. Part of that initiative includes the attached COVID-19 Screening Questions and Treatment Consent that we request to be returned prior to EACH APPOINTMENT. Please call or email the office if you have any questions. Thank you.
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Email *
Today's Date *
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Patient Name *
Q1: Are you immunocompromised? *
Q2:  Do you have any of these symptoms? Choose any or all that are new, worsening and not related to other known causes or conditions.
   •Fever and/or chills
   •Cough or barking cough
   •Shortness of breath
   •Decrease or loss of taste or smell
   •Muscle aches/joint pain
   •Extreme tiredness
   •Sore throat
   •Runny or stuffy/congested nose
   •Headache
   •Nausea, vomiting and/or diarrhea
   •Abdominal pain
   •Pink eye *
Q3: Have you been told (by a doctor, health care provider, public health unit, federal border agent, or other government authority) that you should currently be quarantining, isolating or staying at home? *
Q4: In the last 10 days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self-testing kit? *
Any “yes” response (other than Q1) must be discussed with the managing dentist immediately. 
Treatment Consent: Please be assured that our office has always met or exceeded the requirements set forth for sterilization and infection control from the RCDSO and PHO, and will continue to do so. However, it is possible to contract COVID-19 infection (or any other communicable disease) in any public space. Our office will provide for socially distant appointment scheduling, and also has added a number of new technologies and techniques to the practice to enhance our level of safety. However, due to the nature of the dental treatment, social distance is not possible between the patient and clinical staff/doctor. Exposure to communicable diseases is unlikely but possible. Clicking "yes" below indicates that the risks involved are accepted, and that consent is given for treatment to be provided by the office of Dr. Hiroshi Takagi and staff.
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