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.
Are you (or anyone with you today) currently experiencing any of the following symptoms of COVID-19 identified by Alberta Health Services:
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.
MUST BE COMPLETED AND SIGNED THE DAY OF YOUR TREATMENT
Electronic Signature (Type out your First and Last Name. If under the age of 18, must be signed by parent or guardian.)