COVID-19 Pandemic Dental Treatment Consent Form

Due to the COVID-19 Pandemic we have instituted an additional dental treatment consent form. Please submit the form prior to arrival.

Patient’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 due to the frequency of visits of other 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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I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Alberta Health Services:

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Under 18

  • Fever > 38°C
  • New cough or worsening chronic cough
  • Sore throat or painful swallowing
  • New or worsening shortness of Breath
  • loss of sense of taste or smell

Over 18

  • Fever > 38°C
  • New cough or worsening chronic cough
  • Sore throat or painful swallowing
  • New or worsening shortness of Breath
  • Runny Nose
OR


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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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. 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) and it is not possible to maintain this distance and receive dental treatment.

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OR

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.

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* 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.

Signature:

Printed Name: