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 symptoms resolve, whichever takes longer. If they are exhibiting any of these symptoms, it is suggested they complete the COVID-19 Self-Assessment online tool to determine if they should be tested.
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.
I confirm that I am 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.
OR
I fall into the following high risk category
and my dentist and I have discussed the risks, and I agree to proceed with treatment.
I confirm that to my knowledge I am not currently positive for the novel coronavirus.
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.
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 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 AHS has asked individuals to maintain physical distancing of at least 2 meters (6 feet) and that with dental treatment this is not possible. I agree to proceed with the scheduled dental appointment.
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 am a healthcare worker who has worn appropriate PPE.
I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above listed orthodontic, dental treatment or attend with a patient having treatment completed during the COVID-19 pandemic and consent to the electronic use of this form, via email.
*I certify that I am the parent or legal guardian of the above minor and confirm that the information I entered is accurate and true. *I am at least 18 years old and I have read and agree to the terms of the above agreement.
By typing your name below and initials above, you are electronically signing, initialing and certifying this consent document just as if it were paper.
Today's Date:
Signature:
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