COVID-19 Pandemic Dental Treatment Consent Form

Completion of this form is required prior to any member of the public entering the clinic to help us ensure we keep everyone safe and continue our duty to flatten the curve.
Please complete this form on THE DAY OF your appointment, BEFORE YOU ARRIVE

Due to the frequency of visits of other dental patients, the characteristics of COVID-19, and the characteristics of dental procedures, that I have an elevated risk of contracting COVID-19 simply by being in a dental office.
Alberta Health Services has asked individuals to maintain physical distancing of at least 2metres (6 feet) and it is not possible to maintain this distance and receive dental treatment.

Do you understand?

Are you (or anyone with you today) currently experiencing any of the following symptoms of COVID-19 identified by Alberta Health Services:

Within the past 14 days, have you received a positive diagnosis for COVID-19?
Are you waiting for the results of a laboratory test for COVID-19?
Are you in the high risk category? (Including diabetes, cardiovascular disease, hypertension, lung diseases including moderate to severe asthma, being immunocompromised, or over age 65)
Within the past 14 days, have you (or anyone in your home) traveled outside of Canada?
Within the past 14 days, have you been identified as a contact of someone who has tested positive for COVID-19 or been asked to self-isolate by Alberta Health, the Communicable Disease Control, or any other governmental health agency?

I agree that the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above listed dental treatment completed during the COVID19 pandemic.


Electronic Signature (Type out your First and Last Name. If under the age of 18, must be signed by parent or guardian.)