COVID-19 Pandemic Consent Form - Simple Patient Form - Patient Initials

Please complete this form filling in either your name, your initial and virtually signing the document to acknowledge your acceptance of this form. If you have any questions about this form, please contact us prior to completing the form. All fields are required.

Patient name:

Are you filling out this form for yourself?
Or is someone else filling this form out for the patient (guardian or caregiver)? If so, who

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. (Initial)

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)

I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Alberta Health Services:

  • • Fever > 38°C (Initial)
  • • New cough or worsening chronic cough (Initial)
  • • Sore throat or painful swallowing (Initial)
  • • New or worsening shortness of breath (Initial)
  • • Difficulty Breathing (Initial)
  • • Flu-like symptoms (Initial)
  • • Runny Nose (Initial)
  • • Loss of smell or taste (Initial)

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 following high-risk category and my dentist and I have discussed the risks,
and I consent to proceed with treatment. (Initial)

I confirm that I am not currently positive for the novel coronavirus. (Initial)

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

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)

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)

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)

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)

LIST of DENTAL TREATMENT

By signing below, 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 PATIENT

What email address should this test copy be sent to?

Printed Name: Date Signed: