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Keeping You and Your Family Safe Is Our Top Priority

COVID-19 Pandemic Dental Treatment Consent Form
Patient First Name:
Patient Last Name:
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.
YesNo
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.
YesNo
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.
I confirm that "I AM NOT" presenting any of the following symptoms of COVID-19 identified by Alberta Health Services:

SYMPTOMS:
YesNo
Fever > 38°C
YesNo
New cough or worsening chronic cough
YesNo
Sore throat or painful swallowing
YesNo
New or worsening shortness of breath
YesNo
Difficulty Breathing
YesNo
Flu-like symptoms
YesNo
Runny Nose
PLEASE ALSO CHECK OFF EACH OF THESE BOXES TO CONFIRM THE FOLLOWING STATEMENTS ARE TRUE.
*Note: If you cannot confirm the statement as true, please leave the box blank.
YesNo
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.
High Risk & Exposure

YesNo

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.
YesNo
I confirm that to my knowledge I am not currently positive for the novel coronavirus.
YesNo
I confirm I am not waiting for results of a laboratory test for the novel coronavirus that was ordered due to contact tracing or because I had identified risk factors.
*Please note: Any individual who has gone in for testing on their own volition as an asymptomatic individual does not need to indicate that.
Travel Outside of Canada
YesNo
I verify that I have not returned to Alberta from any country outside of Canada whether by car, air, bus, boat or train in the past 14 days.
YesNo
I understand that any travel from any country outside of Canada, including travel by car, air, bus, boat 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.
Physical Distancing
YesNo
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.
Close Contact
YesNo
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.
OR
YesNo
I verify that I am a healthcare worker who has worn appropriate PPE.
LIST OF DENTAL TREATMENT
I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above listed dental treatment completed during the COVID-19 pandemic.
Signature of Parent/Guardian
Parent/Guardian Name:
Printed Name
Date
(YYYY-MM-DD)

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