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Covid-19 Consent Form
Today's Date
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DD slash MM slash YYYY
Consent
*
Although our dental team has taken precautions to meet or exceed the COVID-19 guidelines mandated by the Alberta Dental Association & College, I understand I have an elevated risk of contracting the novel coronavirus simply by being in a dental office.
*
Not COVID Positive
*
I confirm that I am not currently positive for COVID-19 nor am I waiting for the results of a laboratory test for the novel coronavirus
*
Not Self Isolating
*
I confirm that I am not required to be in quarantine nor been asked to self-isolate at the time of my dental appointment.
*
No Symptoms
I am not presenting any of the following symptoms of COVID-19:
• Fever > 38°C
• New cough or worsening chronic cough
• Sore throat or painful swallowing
• New or worsening shortness of breath
• Difficulty breathing
• Flu-like symptoms
• Runny Nose
Please describe your symptoms:
Name
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By signing below, 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.
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Patient or Parent/Guardian Signature
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Dr. Brandon Earl
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Orthodontics
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Expand
Invisalign
Myobrace
Braces
Orthodontic Fees
Sedation Dentistry
Children’s Dentistry
Dental Hygiene
Contact
Expand child menu
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Contact Us
COVID-19 Patient Consent Form
X-Ray Release Form
New Patient Form
Our Forms