COVID-19 Pandemic Dental Treatment Consent Form

Name of Patient*

First NameLast Name

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)

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 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 or wear a mask 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)

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental hygiene treatment completed during the COVID-19 pandemic.

Patient/Guardian Signature (Please sign in the box below using your mouse, touch screen, or touchpad)*

I accept that this is the legal representation of my signature. By signing above, I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have an in-office appointment at Baseline Village Dental Hygiene completed during the COVID-19 pandemic. I accept the interim policies and procedures that are place and I agree to comply with the expectations.