All Staff are Required to Complete This Consent Form Prior to Each Shift

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


* Required

*Staff Member Name:

*Staff Member Email:

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 certain dental procedures create aerosols which are one way that the novel coronavirus can spread. The ultra-fine nature of the aerosol can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus.

I understand that due to the frequency of visits of other staff, dentists and 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 have been made aware of the Alberta Dental Association and College’s Expectations and Pathway for Patient Care during the COVID-19 Pandemic. I confirm that I have read and understood them.

I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Alberta Health Services:

  • 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 (ex. chills, nauseau, body aches, weakness)
  • Runny Nose
  • Loss of smell or taste

I confirm that I have considered if I am in a high-risk category (factors include; diabetes, cardiovascular disease, hypertension, lung diseases including moderate to severe asthma, being immunocompromised, having active malignancy, age >65) and have chosen to work.

I confirm that 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 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 Alberta Health Services has asked individuals to maintain physical distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and provide or assist with dental treatment.

I verify that I have not been identified as a close contact of a confirmed case of someone who has tested positive for novel coronavirus and/or been asked to self-isolate by Alberta Health, the Communicable Disease Control or any other governmental health agency.

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to work on all dental treatment patients for , during the COVID-19 pandemic. I understand that I may revoke this consent to provide dental treatment or assist with the provision of dental treatment at any time during the day. This means that I may change my mind.

AM Temperature:

PM Temperature:


Printed Name

Date Signed

Thank you for being an integral part of the Strathcona Dental Clinic Team!