Please fill out our covid-19 patient consent form before coming into our office.
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.
I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Alberta Health Services:
Please note: Any individual who has gone in for testing on their own volition as an asymptomatic individual does not need to indicate that.
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 dental treatment completed during the COVID-19 pandemic.