COVID-19 SAFETY UPDATE

More information on our new COVID-19 Safety Procedures can be found here:

Click Here For More Information COVID Treatment Consent Form

COVID-19 Pandemic Visitor Consent Form

CMOH Order 05-2020 legally obligates any person who has the following; cough, fever, shortness of breath, runny nose, or sore throat (that is not related to a pre-existing illness or health condition) to be in isolation (quarantine) for 10 days from the start of symptoms, or until symptoms resolve, whichever takes longer. If they are exhibiting any of these symptoms, it is suggested they complete the COVID-19 Self-Assessment online tool to determine if they should be tested.

Visitor's Name:

E-mail:

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.

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

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I understand that due to the frequency of dental 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 a dental office.

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If I am a contractor visiting Petrolia Dental I understand my employer is responsible for informing me of my rights and responsibilities in relation to Occupational Health & Safety (OHS).

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

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  • 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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  • Difficulty Breathing
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  • Flu-like Symptons
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  • Runny Nose
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I confirm that to my knowledge I am not currently positive for the novel coronavirus.

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

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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.

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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.

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I understand that Alberta Health Services has asked individuals to maintain social distancing of at least 2 metres (6 feet).

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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.

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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.

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I confirm that I will wear a mask the entire time I am at Petrolia Dental.

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I confirm that within 14 days of my visit, if I develop signs and symptoms of COVID-19 as listed above, recieve a diagnosis of COVID-19 or am identified as a close contact of a confirmed COVID-19 case that I visited BEFORE Petrolia Dental that I will inform Petrolia Dental.

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Signature:

Printed Name: