ST. PAUL COVID-19 PANDEMIC DENTAL TREATMENT CONSENT FORM

COVID-19 Pandemic Dental Treatment Consent Form
Patient name:

First NameLast Name
Email:
example@example.com
I confirm that, to my knowledge, I am not currently positive for COVID-19 and am required to isolate in accordance with Alberta provincial health guidelines.
I confirm that I am not waiting for results of a laboratory test for COVID-19.
Please note: If applicable, any individual who has gone in for testing on their own volition as an asymptomatic individual does not need to indicate this.
For patients over 18 years of age, I confirm that I am not presenting any of the following symptoms of COVID-19 as identified by Alberta Health Services:
For patients under 18 years of age, I (as a parent or guardian) confirm that they are not presenting any of the following symptoms of COVID-19 as identified by Alberta Health Services:
I confirm that, to my knowledge, I have not come into contact with someone who has tested positive for COVID-19 and am required to isolate in accordance with Alberta provincial health guidelines.
I confirm that I am not currently subject to a public health or government-mandated quarantine or period of self-isolation.
List of Dental Treatment Required:
I verify the information I have provided on this form is truthful and accurate. I acknowledge that being in a dental clinic increases my risk of contracting COVID-19. I knowingly and willingly consent to have all required and/or recommended dental treatment completed during the COVID-19 pandemic. Please use your mouse or finger to sign below.

(Signature)
Printed Name:

First NameLast Name
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

COVID-19 Pandemic Dental Treatment Consent Form