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4300 S Park Dr #270, Stony Plain, AB T7Z 2W7
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Staff Only: Covid-19 Consent Form
Staff COVID-19 Form
Today's Date
*
DD slash MM slash YYYY
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 certain dental procedures create aerosols which are one way that the novel coronavirus can spread.
Initials
*
First Initial
Last Initial
Dental Office Consent
*
I understand that due to the frequency of visits of other staff, dentists and dental patients, the characteristics of the novel coronavirus, the characteristics of dental procedures and that many dental procedures generate aerosols, that I have an elevated risk of contracting the novel coronavirus simply by being in a dental office.
ADA&C Guidelines Consent
*
I have been made aware of the Alberta Dental Association and College’s Expectations and Pathway for Patient Care during the COVID-19 Pandemic. I confirm that I have read and understand them.
Symptoms
*
By selecting all, I confirm that I am
not
presenting any of the following symptoms of COVOID-19 listed
Select All
Fever > 38°C
New or worsening chronic cough
Sore throat or painful swallowing
New or worsening shortness of breath
Difficulty Breathing
Flu-like symptoms
Runny Nose
Initials
*
First Initial
Last Initial
Consent
*
I confirm I know that there are categories of people who are considered to be high risk. I understand the high risk category factors are being 65 years of age or older, heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder. If I am in one of these categories, I have chosen to work knowing the risk to my health if I develop COVID-19
COVID-19 Consent
*
I confirm that I am not currently positive for the novel coronavirus.
COVID-19 Consent
*
I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus.
Travel outside of Canada
*
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.
Self-isolation consent
*
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.
Physical distancing consent
*
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.
Close Contact consent
*
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.
I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to work on today's date during the COVID-19 pandemic. I understand that I may revoke this consent to provide dental treatment or assist with the provision of dental treatment at any time during the day. This means that I may change my mind.
Name
*
First
Last
Signature
*
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Phone
(780) 968-4414
