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COVID-19 Patient Consent Form

WE REQUIRE THIS FORM BE COMPLETED
PRIOR TO YOUR NEXT APPOINTMENT

To ensure the health and safety of both our patients and staff during the COVID-19 pandemic, we require submission of consent in order for patients and staff to attend appointments.

PLEASE COMPLETE THE PATIENT CONSENT FORM BELOW:

* Required

CMOH Order 05-2020 legally obligates any person who has the following cough, fever, shortness of breath, runny nose, or sore throat (that is not related to a pre-existing illness or health condition) to be in isolation (quarantine) for 10 days from the start of symptoms, or until symptoms resolve, whichever takes longer. If they are exhibiting any of these symptoms, it is suggested they complete the COVID-19 Self-Assessment online tool to determine if they should be tested.


*Patient Name:

*Patient E-mail:

Or is someone else filling this form out for the patient? If so, who .

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

OR

I fall into the following high-risk category and my dentist and I have discussed the risks, and


Please note: Any individual who has gone in for testing on their own volition as an asymptomatic individual does not need to indicate that.


Or

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

Printed Name  Date Signed



Our dental practice always welcomes new patients no referral is required!