Patient Acknowledgement

1 905 497-5330Contact Number

Monday - Friday10AM - 7PM

Saturday 10 AM - 4 PM

68 Bramalea Rd., Unit 2&3
Brampton, On L6T 0H2
Tel: 9054975330, Fax:9054975332
www.BramaleaSmilesDentistry.ca
1. I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand that 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, I understand that the federal and provincial authorities have recommended that Ontarians stay home and avoid close contact with other people when at all possible.*
Initial
2. I understand the federal and provincial authorities have asked individuals to maintain social distancing of a least two (2) meters (six (6) feet) and I recognize it is not possible to maintain this distance while receiving dental treatment.*
Initial
3. I understand that oral surgery/dental procedures can create water and/or blood spray, which is one way that the novel coronavirus can spread. I understand that the ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus.*
Initial
4. 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 the novel coronavirus simply by being in the dental office.*
Initial
5. I confirm that I do NOT have any TWO OR MORE or the following symptoms of COVID-19: (i) fever, (ii) new or worsening cough, (iii) sore throat, (iv) runny nose or (v) headache.*
Initial
6. If I received COVID-19 test results in the past three (3) months, the last results I received were negative.*
7. If applicable, approximate date of test:
Date Format: MM slash DD slash YYYY
8. I confirm that I am not waiting for the results of a test for COVID-19.*
Initial
9. I confirm that this is not currently a period during which public health authorities required I self-isolate for 14 days.*
Initial
I verify the information I have provided on this form is truthful and complete. I knowingly and willingly consent to have emergency surgical/dental treatment completed during the COVID-19 pandemic.
Full Name*
Consent*
I hereby Sign in Electric as my legal signature.
I hereby Have my Initial And Sign
Signature*

Bramalea Smiles Dentistry.

A team working to ensure you receive the best treatment.

1 905 497-5330

info@bramaleasmilesdentistry.ca

Bramalea Smiles Dentistry

Our Service

Google Reviews

      
   Bramalea Smiles Dentistry
   22 Google reviews 
  Write a review 
  
 
 
   
 
 
        
   Sherlini Ramrup 
 2020-08-25
 
 
  Excellent service.
  
 
       
   Manohar Sah 
 2020-08-19
 
 
  I have visited last year 2019 to tooth fill up. After a week started a  problem. I contacted them specially dr Anita. She asked me to come back with no charges. I went there. Dr Anita fixed it but one month later again started more big problems. Dr Anita has no good experience. She is new learner dentist. Also charge a large bill. It’s a one kind of robing people. Unnecessary extra charge for X-ray.   do not provide a receipt too.  I do not recommend any person to go there. Better search experience dentist in your area.
Hospitality is very poor. Specially Ashok yadav at reception had very poor attitude. In totality,  I felt it’s a cheating and wrong place for treatment.  No good knowledge about dental treatment. Be careful !!!!
  
 
       
   Madhav Niroula 
 2020-03-06
 
 
  Nice dental place in Bramalea area. Dr Gupta is an expert at what she does. She’s very friendly, and is willing to accommodate if you have special requirements. They are also flexible with time of appointments and in fact agreed to close the place after their usual closing time for me. I have been there more than 3 times, and will return. Recommended!!
  
 
       
   okay 
 2019-12-30
 
 
  Very nice place . Very professional and clean. Knowledgeable doctor and staff.
  
 
       
   Satish Dangi 
 2019-12-15
 
 
  Highly recommended place.
  
 
       
   neeru acharya 
 2019-10-14
 
 
  "Very Pleasant Indeed"
It was a very pleasant meeting with Dr Anita and her team. I was suffering from a toothache and infection very badly. I was thinking of removing my tooth as it was bothering a lot . She is very professional in  explaining and providing valuable suggestions and options. I must say "Thank you" for saving my tooth. I felt like two hours for my procedure went by so quick. It is  not easy to find a good Dentist for a family and especially for Kids. My daughter says "I like my Dentist".
I highly recommend Dr. Anita  and her team for your Family .
  
 
       
   Shahbaz Ahmad 
 2019-09-29
 
 
  Great service,Dr. Anita is Very Professional and qualified.... she has removed my  cavities and did the filling... and I was just watching the TV... didn’t feel any pain.. strongly Recommend...Friendly Staff..👍🏻
  
 
       
   North Star 
 2019-07-28
 
 
  Fully satisfied with the service. The best part is that Dr. Gupta carefully listens to you and gives adequate time for your dental needs. Thanks
  
 
       
   Supriya R 
 2019-06-30
 
 
  I was so scared of going to dentist.... always tried to cancel/postponed my appointment.
When I went for a consult appointment..... I could see what was going on and Dr. Anita was so kind, honest and understanding and she took the time to address my concerns. Also loved the staff and office...

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