Covid-19 Consent Form

Today's Date*
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*
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.
First Name Last Name
Signature*
Patient or Parent/Guardian Signature

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