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 carriers of the virus may not show symptoms and still be contagious.

I understand that certain dental procedures create aerosols which are one way that the novel coronavirus can spread.

I understand that due to the frequency of visits of other dental staff, 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 a dental office.

I have been made aware of the Alberta Dental Association and College’s Expectations and Pathway for Patient Care during the COVID-19 Pandemic. I confirm that I have read and understand them.

I have received training on the occupational health and safety controls that have been implemented at my workplace to minimize the risk of COVID-19 transmission.

I confirm that I am not presenting any of the following symptoms of COVOID-19 identified by Alberta Health Services:

• Fever > 38°C
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• New cough or worsening chronic cough
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• Sore throat or painful swallowing
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• New or worsening shortness of Breath
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• Runny Nose
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I confirm I know that there are categories of people who are considered to be high risk. I understand the high risk category factors are being 65 years of age or older, heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder. If I am in one of these categories, I have chosen to work knowing the risk to my health if I develop COVID-19.

I confirm that to my knowledge I am not currently positive for the novel coronavirus.

I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus.

Please note: Any individual who has gone in for testing on their own volition as an asymptomatic individual does not need to indicate that.

I verify that I have not returned to Alberta from any country outside of Canada whether by car, air, bus or train in the past 14 days.

I understand that any travel from any country outside of Canada, including travel by car, air, bus or train, significantly increases my risk of contracting and transmitting the novel coronavirus. Canadian and Alberta Health Services require self-isolation for 14 days from the date a person has returned to Canada.

I understand that Alberta 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 provide dental treatment.

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 Alberta Health, the Communicable Disease Control or any other governmental health agency.

I confirm that I have or will be disinfecting my hands and taking my temperature upon entering the office and will record it on the daily log. If my temperature is greater than 38 degrees Celcius I will immediately inform the dentist in that day. I will immediately place a surgical mask on my face.

I confirm that I am not a participant in the International Border Pilot Testing Program OR I have participated, but have waited the 14 days required after return.

* If you have participated in the International Border Testing Program you understand that you are not permitted to enter a healthcare facility for 14 days after return from travel.

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to work on ___TODAY_____ during the COVID-19 pandemic. I understand that I may revoke this consent to provide dental treatment or assist with the provision of dental treatment at any time during the day. This means that I may change my mind.