Parent/Guardian Name (if applicable)
Date *
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. (Initial) *
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. (Initial) *
If Yes to the above, please list location of workplace
I confirm that to my knowledge, I am not currently positive for the novel coronavirus. (Initial) *
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. (Initial) *
OR I fall into a high-risk category and my dentist and I have discussed the risks, and I agree to proceed with treatment. (Please name category below and initial)
I confirm I am not waiting for results of a laboratory test for the novel coronavirus that was ordered due to contact tracing or because I had identified risk factors. Please note: Any individual who has gone in for testing on their own volition as an asymptomatic individual does not need to indicate that. (Initial) *
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. (Initial) *
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. (Initial)
OR I verify that I am a healthcare worker who has worn appropriate PPE. (Initial)
I understand that if I test positive for COVID-19 within 14 days of my last dental visit at Lakeside Dental of Mahogany, I must notify them immediately. (Initial) *
I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic. (Initial) *
LEGAL NAME of Patient/Parent/Guardian *
