Your Name (required)
Your Email (required)
Phone (required)
Describe your dental emergency: (required)
Upload a photo: (required)
Please read the following and click "Yes" for each statement you agree with and "No" if you don't agree:
I understand that the Provincial Dental Association and College guidelines state that under the current pandemic all non-urgent dental care is not allowed. Dental visits should be limited to the treatment of ongoing tissue bleeding, alleviate severe pain or infection or conditions that significantly inhibit normal operation of teeth and mouth, and issues that may cause anything listed above within the next 3 to 6 months: (required)
—Please choose an option—YesNo
I confirm I am seeking treatment for a condition that meets these criteria: (required)
I confirm that I am not currently positive for the novel coronavirus: (required)
I confirm that I am not waiting for the results of a laboratory test for Covid 19: (required)
I verify that I have not returned to Ontario from another country in the past 14 days: (required)
I understand that any travel from another country significantly increases my risk of contracting and transmitting the novel coronavirus. I realize Provincial Health Services require self-isolation for 14 days from the date a person has returned to Canada: (required)
I understand that Provincial Health Services has asked individuals to maintain social distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive dental treatment: (required)
I verify that I have not been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by Provincial Health, the Communicable Disease Control or any other governmental health agency: (required)
