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Dr. Jagatjit Dhillon
Dr. Alexandra Moore
Dr. Aaron Mah
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Covid-19 Consent Form
COVID-19 CONSENT FORM
Today's Date
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DD slash MM slash YYYY
Consent
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Although the dental team has met or exceeded the precautions mandated by Alberta Health Services and the Alberta Dental Association & College, I understand I have an elevated risk of contracting the novel coronavirus simply by being in a dental office.
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Not COVID Positive
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I confirm that I am not currently positive for COVID-19 nor am I waiting for the results of a laboratory test for the novel coronavirus.
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Not Self Isolating
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I confirm that I am not required to be in quarantine nor been asked to self-isolate at the time of my dental appointment.
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Not Symptomatic
I am not presenting any of the following symptoms of COVID-19:
• 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
Please describe your symptoms:
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By signing below, 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.
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Who We Are
Expand child menu
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Dr. Jagatjit Dhillon
Dr. Alexandra Moore
Dr. Aaron Mah
How We Can Help
Expand child menu
Expand
General Dentistry
Expand child menu
Expand
Dental Exam
Dental Implants
Root Canal
Tooth Removal
Emergencies
TMJ Therapy
Sedation Dentistry
Wisdom Teeth Removal
Cosmetic Dentistry
Expand child menu
Expand
Teeth Whitening
Veneers
Crowns and Onlays
Bridges vs Implants
Orthodontics
Expand child menu
Expand
Invisalign
Braces
Myobrace
Snore Centre
Hygiene
Office Forms
Expand child menu
Expand
New Patient Form
X-Ray Form
COVID-19 Consent Form
Schedule Your Appointment
