Covid-19 Staff Member Consent Form

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. Initial*

I understand that certain dental procedures create aerosols which are one way that the novel coronavirus can spread.Initial*

I understand that due to the frequency of visits of other staff, dentists and dental patients, the characteristics of the novel coronavirus, the characteristics of dental procedures and that many dental procedures generate aerosols 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’s Expectations and Pathway for Patient Care during the COVID-19 Pandemic. I confirm that I have read and understand them. 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. If I am in one of these categories, I have chosen to work knowing the risk to my health if I develop COVID-19. Initial*

I confirm I am not waiting for results OR been in close contact with a person waiting for results of a laboratory test for the novel coronavirus that was ordered due to contact tracing or because I had identified risk factorsInitial*

I verify that I have not returned to Alberta from any country outside of Canada whether by car, air, bus, boat 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, boat 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 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 work on   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.