COVID-19 Pandemic Dental Treatment Consent Form

Patient Full Name

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:

Do you have a fever > 38°C?

Yes

No

New cough or worsening chronic cough?

Yes

No

Sore throat or is it painful swallowing?

Yes

No

New or worsening shortness of breath?

Yes

No

Difficulty Breathing?

Yes

No

Flu-like symptoms?

Yes

No

Runny nose?

Yes

No

I confirm I know that there are categories of people who are considered to be high risk. I understand the high-risk category factors are being 65 years of age or older, heart disease, lung disease, kidney disease, diabetes, or an auto-immune disorder.

or

I fall into the following high-risk categories and my dentist and I have discussed the risks, and I have agreed to proceed with treatment.

I confirm that I am not currently positive for the novel coronavirus.

I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus.

I verify that I have not returned to Alberta from any country outside of Canada whether by car, air, bus, or train in the past 14 days.

I understand that any travel from any country outside of Canada, including travel by car, air, bus or train, significantly increases my risk of contracting and transmitting the novel coronavirus. Alberta Health Services require self-isolation for 14 days from the date a person has returned to Canada.

I understand that Alberta Health Services has asked individuals to maintain physical distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive dental treatment.

I verify that I have not been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by Alberta Health, the Communicable Disease Control or any other governmental health agency.

I verify 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 COVID-19 pandemic.

Patient Signature

Date

Thank you for submitting your COVID-19 Consent Form

AT WESTSIDE ENDODONTICS WE ARE ADHERING TO ALL COVID-19 PROTOCOLS FROM THE ALBERTA DENTAL ASSOCIATION & COLLEGE AS WELL AS ALBERTA HEALTH SERVICES TO KEEP OUR PATIENTS & STAFF SAFE.

Call to schedule

an appointment with us.

(403) 457-8400

14 – 7400 Macleod Trail SE
Calgary, AB T2H 0L9

Phone: (403) 457-8400

Fax: (403) 775-4409

Email: info@wsendodontics.com

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