COVID-19 Patient Consent

WE REQUIRE THIS FORM BE COMPLETED PRIOR TO YOUR NEXT APPOINTMENT

To ensure the health and safety of both our patients and staff during the COVID-19 pandemic, we require the submission of the COVID-19 Patient Consent form in order for patients and staff to attend appointments.

All patients are required to review and submit a COVID-19 Patient Consent form prior to coming in for their appointment.

PLEASE COMPLETE THE PATIENT CONSENT FORM BELOW:

* Required

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.

*Your Email:

*This form is being reviewed and submitted by: (Patient Name) *

For All Patients - Have you experienced flu-like symptoms (fever, cough, sore throat, shortness of breath, runny nose (if over 18 years old) in the last 10 days?
YesNo

Travel - Have you travelled outside of Canada in the last 14 days?
YesNo

Close Contact - Have you been in close contact with anyone testing positive for Covid-19 in the last 14 days?
YesNo

I consent to being treated in a dental office where risks of contracting COVID-19 may be elevated (inability to physical distance, aerosol generating procedures).*
I understand and agree

I, (patient name entered below), agree that the digital submission of this consent form holds me in acceptance to the above form. This electronic agreement shall be considered legal and binding.*

SIGNATURE OF PATIENT

Date Signed

Thank you from the Team at Strathcona Dental!

WE REQUIRE THIS FORM BE COMPLETED PRIOR TO YOUR NEXT APPOINTMENT

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