COVID-19 Pandemic - Support Staff - Daily Consent Form

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.

Staff Member 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.

I understand that certain dental procedures create aerosols which are one way that the novel coronavirus can spread. The ultra-fine nature of the aerosol can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus.

I understand that due to the frequency of visits of other staff, dentists and 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 have been made aware of the Alberta Dental Association and College Guidelines that under the current pandemic all non-emergent dental care is not allowed. Dental visits should be limited to the treatment of emergency patients only. I confirm that I have read and understand the Guidelines on Emergency Treatment. (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)
  • • Cough (Initial)
  • • Sore Throat (Initial)
  • • Shortness of Breath (Initial)
  • • Difficulty Breathing (Initial)
  • • Flu-like symptoms (Initial)
  • • Runny Nose (Initial)

I confirm that I have considered if I am in high risk category (factors include; diabetes, cardiovascular disease, hypertension, lung diseases including moderate to severe asthma, being immunocompromised, having active malignancy, age >65) and have chosen to work. (Initial)

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

I confirm that I am not waiting for 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 provide or assist with dental treatment. (Initial)

I verify that I have not been identified as a close contact of a confirmed case of someone who has tested positive for novel coronavirus and/or been asked to self-isolate by Alberta Health, the Communicable Disease Control or any other governmental health agency. (Initial)

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to work on all dental treatment patients for , 2020 (insert date) during the COVID-19 pandemic. I understand that I may revoke this consent to provide dental treatment or assist with the provision of dental treatment at any time during the day. This means that I may change my mind.

SIGNATURE OF STAFF MEMBER

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