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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.








    I understand and agree

    SIGNATURE OF PATIENT

    Date Signed

    Thank you from the Team at Strathcona Dental!