We Require This Form To Be Completed Prior To Your Next Appointment!

To ensure the health and safety of both our patients and staff during the COVID-19 pandemic, we require the submission of a COVID-19 patient consent form in order for patients and staff to attend appointments.

All patients are required to review and submit a patient consent form prior to coming in for their next dental appointment.

PLEASE COMPLETE THE PATIENT CONSENT FORM BELOW:

* Indicates Required

CMOH Order 05-2020 legally obligates any person who has the following cough, fever, shortness of breath, runny nose, or sore throat (that is not related to a pre-existing illness or health condition) to be in isolation (quarantine) for 10 days from the start of symptoms, or until symptoms resolve, whichever takes longer. If they are exhibiting any of these symptoms, it is suggested they complete the COVID-19 Self-Assessment online tool to determine if they should be tested.

    *Patient Name:

    *Patient E-mail:

    Or is someone else filling this form out for the patient? If so, who .

    For Patients Over 18 - I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Alberta Health Services:

    For Patients Under 18 - I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Alberta Health Services:



    OR

    I fall into the following high-risk category and my dentist and I have discussed the risks, and



    Travel During the Pandemic


    Or

    By signing below, 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

    Printed Name

    Date Signed

    Thank you from the Team at Dimension Dentistry!

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