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 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.
The patient's age is:
18 years or overunder 18 years
For Patients 18 and over
, I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Alberta Health Services:
For Patients under 18
, I confirm that they are not presenting any of the following symptoms of COVID-19 identified by Alberta Health Services:
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 fall into the following high risk categories
none65 years of age or olderheart diseaselung diseasekidney diseasediabetesauto-immune disorder
and my dentist and I have discussed the risks, and I have agreed to proceed with treatment.
I confirm that to my knowledge I am not currently positive for the novel coronavirus.
I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus.
I verify that I have not returned to Alberta from any country outside of Canada whether by car, air, bus, boat or train in the past 14 days.
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.