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Dr. Jagatjit Dhillon
Dr. Alexandra Moore
Dr. Aaron Mah
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Schedule Your Appointment
Contact Us
Menu
Who We Are
Dr. Jagatjit Dhillon
Dr. Alexandra Moore
Dr. Aaron Mah
How We Can Help
General Dentistry
Dental Implants
Root Canal
Tooth Removal
Emergencies
TMJ Therapy
Sedation Dentistry
Cosmetic Dentistry
Teeth Whitening
Veneers
Crowns and Onlays
Bridges vs Implants
Orthodontics
Invisalign
Braces
Myobrace
Snore Centre
Hygiene
Office Forms
New Patient Form
X-Ray Form
COVID-19 Consent Form
Schedule Your Appointment
Contact Us
COVID-19 CONSENT FORM
Today's Date
*
Date Format: DD slash MM slash YYYY
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 dental procedures create water and/or blood spray which is one way that the novel coronavirus can spread.
Initials
*
First Initial
Last Initial
Dental Office Consent
*
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.
Symptoms
*
By selecting all, I confirm that I am
NOT
presenting any of the following symptoms of COVID-19 listed
Select All
Fever > 38°C
New cough or worsening chronic cough
Sore throat or painful swallowing
New or worsening shortness of breath
Difficulty Breathing
Flu-like symptoms
Runny Nose
Initials
*
First Initial
Last Initial
Consent
*
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.
OR
I fall into the high risk category and my dentist and I have discussed the risks, and I agree to proceed with treatment.
COVID-19 Consent
*
I confirm that I am not currently positive for the novel coronavirus.
COVID-19 Consent
*
I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus.
Initials
*
First Initial
Last Initial
Travel outside of Canada
*
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.
Self-isolation consent
*
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.
Physical distancing consent
*
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 consent
*
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 verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.
Name
*
First
Last
Patient/Guardian Signature
*