Some *new* and hopefully temporary protocols for Donly Dental are:

  • Our team will be wearing PPE and have barriers now to protect everyone
  • Please stay in your car and text us when you arrive
  • Please wear a mask when you enter
  • We will be taking your temperature prior to your appointment
  • Please use hand sanitizer when you enter
  • Please make sure you use the washroom and brush your teeth BEFORE coming
  • Only patient per appointments (or 1 parent per child) are permitted into the office
  • Please reschedule your visit if anyone in your household has been sick in the last 14 days

Thank-you for your patience and look forward to seeing you!

Your friends at Donly Dental

    Covid-19 Pre-Screen & Patient Acknowledgement Form

    Pre-Screen Information




    Date of Birth:

    Appointment Date:

    New or Existing Patient:
    New PatientExisting Patient

    Covid Vaccination Status
    Current status of vaccination against Covid-19?

    Brand of Vaccine (if multiple, please write each brand):

    Date of Last Covid-19 Vaccine Dose:

    Exposure & Symptom Confirmation

    Do you have a fever or have felt hot or feverish anytime in the last two weeks?

    Do you have any of these symptoms: Dry cough, shortness of breath, difficulty breathing, sore throat, runny nose or any nasal congestion, difficulty swallowing, decrease or loss of sense of smell or taste, chills, headaches, unexplained fatigue or muscle aches, nausea, vomiting, diarrhea, abdominal pain, pink eye?

    Have you had a confirmed case of COVID-19?

    Have you been in contact with anyone that has been confirmed COVID-19 positive, or persons self-isolating because of a determined risk for COVID-19, or with anyone with acute respiratory illness?

    Have you returned from travel outside of Canada in the last 14 days?

    Have you been in close contact with anyone that has travelled outside of Ontario in the past 14 days?

    Are you over the age of 70 that have experienced any of the following symptoms: delirium, unexplained or increased number of falls, worsening of chronic conditions, or acute functional decline?

    Covid-19 Patient Acknowledgement

    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 and accept:

    I understand our government have asked individuals to maintain social distancing of at least 6 feet and I recognize it is not possible to maintain this distance while receiving dental treatment.
    I understand and accept:

    I understand there is an elevated risk of contraction of the novel coronavirus due to other patients, the characteristics of the virus and dental procedures.
    I understand and accept:

    I confirm that I am not waiting for the results of a test for COVID-19 and that I have not been tested positive for COVID-19 in the past.
    I confirm this statement:

    If I received COVID-19 test results in the past 3 months, the last results I received were negative.
    This statement is true:
    YESNOI was not tested

    Approximate date of Covid-19 test if applicable:

    I confirm that this is not currently a period where I am required to self-isolate for 14 days.
    I confirm this statement:

    Information Update

    Any new medications or medical conditions/issues?

    List of new medications and/or any new medical conditions/issues?

    Insurance, phone number or address changes?

    Would you like a different type of reminder/notification:
    TextEmailVoice Call

    I verify the information I have provided on this Patient Acknowledgement Form is truthful and accurate. I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.

    Your Signature:
    Use your mouse to sign on computer, or finger on a mobile device

    Please make sure you've filled out all of the required fields.
    If you are still having trouble submitting the form, you can try a different browser.
    (Chrome is recommended).


    8:00am – 7:00pm


    8:00am – 7:00pm


    8:00am – 7:00pm


    8:00pm – 7:00pm


    8:00am – 5:00pm


    By Appointment Only

    Coming from out of town? Follow directions to Donly Dental. Now welcoming new dental patients from Delhi and Port Dover!

    Fill out this form and we'll get right back to you!

      New PatientExisting Patient