Northwest - Patient COVID Wellness and Consent

In response to the recent COVID-19 Pandemic, the health and well-being of you, your family and the team at OrthoGroup is our highest priority. In order to gain access to our practice, please confirm the following for each person attending the appointment (including parent/guardian). please check each item and sign below

I have not tested positive for COVID-19.
I am feeling healthy today and cannot think of any reason why I should not be allowed to access the practice today
I do not currently have any symptoms of COVID-19 (flu-like symptoms, fever, chills, cough, sore throat, runny nose, muscle aches, severe exhaustion / weakness, shortness of breath, difficulty breathing.)
I have not had a fever of 38C / 100.4F or greater within the past 72 hours.
I will strictly follow all known physical distancing recommendations and guidelines while in and around OrthoGroup including respecting a distance of more than 2 meters from other individuals

During the previous 10 days I have not:

been advised to self-isolate or quarantine by a doctor or health authority
had close face-to-face contact with any person who was symptom free but developed COVID-19 within 48 hours of our contact

Patient Pandemic Informed Consent

Our office follows all requirements for Infection Control and Prevention, including all enhanced directives issued by the Public Health Agency of Canada and related Federal and Provincial health authorities. Our clinic and all treatment areas are sterilized frequently, including after each dental procedure and patient visit. We take all the necessary precautions to prevent transmission of the COVID-19 virus along with any and all other known infection-causing viruses or bacteria.

I understand that the novel coronavirus causes the disease known as COVID-19. I understand that 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 interactions of staff and 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 an orthodontic office.

I verify that I have not been identified as a close contact of a confirmed case of someone who has tested positive for COVID-19, nor have I been asked to self-isolate by Alberta Health, or by a related medical authority or other governmental health agency.

By signing this consent form, I verify the information I have provided on the Patient Health Declaration and the Patient Pandemic Informed Consent form is truthful and accurate. I knowingly and willingly consent to have OrthoGroup provide orthodontic treatment for myself or for my child,

(PRINT NAME),

despite the elevated risks associated with treatment during this time of COVID-19 pandemic.

Signature of Patient/Parent/Guardian

Date