I understand it is recommended to maintain social distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive denture treatment.

I verify that I have not been in contact with someone who has tested positive for novel coronavirus or been asked to self-isolate by any governmental health agency.

I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus virus has a long incubation period, during which time, carriers of the virus may not show symptoms and may still be contagious. I understand that due to the frequency of visits of other denture patients, the characteristics of the novel coronavirus, and the characteristics of denture procedures, that I have an elevated risk of contracting the novel coronavirus simply by being in a denturist office.