Consent/Covid-19 Pre-Screening Form

COVID-19 Pre-Screening Form

Patient 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 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. (Int.)

I confirm I am not presenting any of the following symptoms of COVID-19 identified by Alberta Health Services:

• Fever > 38°C

(Int.)

• Cough

(Int.)

• Sore Throat

(Int.)

• Shortness of Breath

(Int.)

• Difficulty Breathing

(Int.)

• Flu-like symptoms

(Int.)

• Runny Nose

(Int.)

I confirm I am not in a high risk category, including: diabetes, cardiovascular disease, hypertension, lung diseases including moderate to severe asthma, being immunocompromised, having active malignancy, or over age 65. (Int.)

I fall into the following high risk category and my dentist and I have discussed the risks, and I agree to proceed with treatment. (Int.)

I confirm that I have not currently tested positive for the novel coronavirus. (Int.)

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

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. (Int.)

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. (Int.)

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. (Int.)

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. (Int.)

Additional comments:

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.

SIGNATURE OF PATIENT/GUARDIAN
(sign with mouse)

Patient Name:

Date