COVID-19 Consent Form

COVID-19 Consent Form

  • DD slash MM slash YYYY

  • 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 dental procedures create water and/or blood spray which is one way that the novel coronavirus can spread.

  • 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 (by checking Select all, you confirm you are not presenting any of the symptoms listed 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.