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Covid-19 Consent Form
COVID-19 CONSENT FORM
Today's Date
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DD slash MM slash YYYY
Consent
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Although our dental team has taken precautions to meet or exceed the COVID-19 guidelines mandated by the Alberta Dental Association & College, I understand I have an elevated risk of contracting the novel coronavirus simply by being in a dental office.
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Not COVID Positive
*
I confirm that I am not currently positive for COVID-19 nor am I waiting for the results of a laboratory test for the novel coronavirus
*
No Quarantine
*
I confirm that I am not required to be in quarantine nor been asked to self-isolate at the time of my dental appointment.
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No symptoms
I am not presenting any of the following symptoms of COVID-19:
• Fever > 38°C
• New cough or worsening chronic cough
• Sore throat or painful swallowing
• New or worsening shortness of breath
• Difficulty breathing
• Flu-like symptoms
• Runny Nose
Please describe your symptoms.
Name
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By signing below, 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.
First Name
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Patient/Guardian Signature
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Dentistry Made Simple.
Thanks For Filling In Our Form.
About
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Expand
Our Office
Our Team
Toggle child menu
Expand
Dr. Jeff Bullock
Dr. Do Hyun Sung
Services
Toggle child menu
Expand
General Dentistry
Toggle child menu
Expand
Exam
Hygiene
Fillings
Sedation Dentistry
Extractions
Root Canal
TMJ Treatment
Teeth Whitening
Restorative Dentistry
Toggle child menu
Expand
Veneers
Crowns
Bridges
Implants
Children’s Dentistry
Periodontal Health
Emergency Dentistry
Orthodontics
Toggle child menu
Expand
30 Second Smile Test
Braces
Invisalign
Toggle child menu
Expand
Invisalign vs Braces
Calgary Ortho Costs
Contact Us
Toggle child menu
Expand
Our Nearby Location
Our Forms
Toggle child menu
Expand
New Patient Form
X-Ray Release Form
Book Now