Patient's 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. (Please initial) *

I understand that Alberta Health Services has asked individuals to maintain physical distancing of at least 6 feet and it is not possible to maintain this distance while receiving dental treatment. (Please initial) *

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. (Please initial) *

I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Alberta Health Services: Fever > 38°C, Cough, Sore Throat, Shortness of Breath, Loss of sense of taste or smell, Runny Nose. (Please initial) *

I verify that I have not returned to Canada from any other country in the past 14 days and understand that if I have traveled outside of Canada, I am required to self-isolate for 14 days upon my return. (Please initial) *

I confirm that I am not a participant in the International Border Pilot Testing Program and I understand that it's participants are not permitted to enter a healthcare facility (including dental offices) for 14 days after return from travel. *

I confirm that I am not currently positive for the novel coronavirus. (Please initial) *

I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus. (Please initial) *

I understand that if I have to quarantine or have tested positive for Covid-19 I cannot enter a healthcare facility (including dental offices) for 10 days or until my symptoms have resolved, whichever is LONGER. (Please initial)

I confirm 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. (Please initial)

OR; I verify that I am a healthcare worker who has worn appropriate PPE. (Please initial here if applicable)

I understand there are categories of people who are considered more high risk. Including those who are 65 years of age and older, have heart disease, lung disease, kidney disease, diabetes or any other auto-immune disorder. (Please initial) *

If you fall into a high risk category, please specify below and discuss the risks versus the benefits with Dr. Caouette prior to proceeding with treatment.

I understand that if I develop Covid symptoms or receive a positive Covid diagnosis in the 14 days after my appointment, I am required to notify South Central Dentistry immediately. (Please initial) *

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above listed emergency or urgent dental treatment completed during the COVID-19 pandemic. Please type your full name here. *