366 Saddleback Rd NW, Edmonton
Call Us: 780-437-4816
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Checkups & Cleaning
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Forms
Covid-19 Pandemic Dental Treatment Questionnaire
Do you have a fever or have felt hot or feverish anytime in the last 10 days?
*
Yes
No
Do you have any Covid-19 or Flu-Like Symptoms?
*
Yes
No
Have you experienced a recent loss of smell or taste?
*
Yes
No
Have you been in contact with anyone who has been confirmed or suspected to be infected with Covide-19?
*
Yes
No
Have you travelled inside or outside of Canada in the last 14 days?
*
Yes
No
Is your workplace considered high risk? (Healthcare workers who have worn appropriate PPE may answer No)
*
Yes
No
Are you over the age of 65?
*
Yes
No
Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?
*
Yes
No
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 sympotoms resolve, whichever takes longer. If you are exhibiting any of these symptoms, it is suggested you complete the COVID-19 Self-Assessment online tool to determine if you should be tested.
Please click to confirm you have read understand all the below:
I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus has a long incubation period during which carriers of the virus may be not show symptoms and still be contagious.
*
I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus has a long incubation period during which carriers of the virus may be not show symptoms and still be contagious.
I understand that due to the frequency of visits of other dental patiens, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have anb elevated risk of contracting the novel coronavirus simply by being in a dental office.
*
I understand that due to the frequency of visits of other dental patiens, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have anb elevated risk of contracting the novel coronavirus simply by being in a dental office.
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.
*
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 fall into one of the above high risk categories, I confirm I have discussed the riskswithmydentistand have agreed to proceed with the treatment. (If you have not discussed the risks with your dentist, please do so before attending your appointment.)
*
If I fall into one of the above high risk categories, I confirm I have discussed the riskswithmydentistand have agreed to proceed with the treatment. (If you have not discussed the risks with your dentist, please do so before attending your appointment.)
I confirm that to my knowledge I am not currently positive for the noval coronavirus.
*
I confirm that to my knowledge I am not currently positive for the noval coronavirus.
I understand that any travel from any country outside of Canada, including travel by car, air, bus, boat 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.
*
I understand that any travel from any country outside of Canada, including travel by car, air, bus, boat 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.
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.
*
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.
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 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 confirm that if I am a healthcare worker that I have worn the appropriate PPE at all times during the course of my work.
I confirm that if I am a healthcare worker that I have worn the appropriate PPE at all times during the course of my work.
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.
Patient Name
*
Patient Age
*
Signature
*
Date
*
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