COVID-19 Pandemic Patient Dental Treatment Consent Form

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Full Name *

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. Initial below. *

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. Initial below. *

For patients over 18, I confirm that I am NOT presenting any of the following core symptoms of COVID-19 as identified by Alberta Health Services:

NO fever > 38 degree celsius

NO cough

NO sore throat

NO shortness of breath

NO runny nose

For patients under 18, I confirm that they are NOT presenting any of the following core symptoms of COVID-19 as identified by Alberta Health Services:

NO fever > 38 degree celsius

NO cough

NO loss of sense of taste or smell

NO shortness of breath

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. Initial below. *

IF YOU ARE OLDER THAN 65 YEARS OLD, HAVE HEART DISEASE, LUNG DISEASE, KIDNEY DISEASE, DIABETES OR ANY AUTO-IMMUNE DISORDER, PLEASE INITIAL BELOW. I fall into the following high risk categories and my dentist and I have discussed the risks, and I have agreed to proceed with treatment.

I confirm that I am not currently positive for the novel coronavirus. Initial below. *

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

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. Initial below. *

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. Initial below. *

I confirm that I am not a participant in the International Border Pilot Testing Program. Initial below. *

I understand that Alberta Health Services has asked individuals to maintain physical distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive dental treatment. Initial below. *

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. Initial below. *

If you are a health care worker - I verify that I am a healthcare worker who has worn appropriate PPE. Initial below.

My dental treatment is

I knowingly and willingly consent to have the above listed dental treatment completed during the COVID-19 pandemic. I understand that by printing my name below I am attesting that the above information is true, accurate and complete to the best of my knowledge. Print FULL NAME below. *

Today's date: *

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