*Patient Name:

    *Patient E-mail:

    Are you filling out this form for yourself? Or is someone else filling this form out for the patient? 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 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:

    • Fever > 38°C (in the last 10 days)
    • New or worsening cough
    • Sore throat
    • Shortness of breath or difficulty breathing
    • Runny nose or nasal congestion
    • Headache
    • Loss of sense of smell or taste
    • Unexplained fatigue/malaise/muscle aches

    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.

    I confirm to my knowledge that I am not currently positive for the novel coronavirus.

    I confirm I am not waiting for results of a laboratory test for the novel coronavirus

    I verify that I have not returned to Alberta from any country outside of Canada within the past 14 days.

    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.

    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
    I verify that I am a healthcare worker who has worn appropriate PPE.

    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.

    SIGNATURE OF PATIENT/PARENT/GUARDIAN

    Printed Name

    Date Signed

    "Providing family, children's, and general dentistry to South Calgary including Riverbend, Ogden, Kingsland, Fairview, Langdon, Okotoks, High River and Surrounding Area"