Complete oral health starts here and now!
I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Alberta
I confirm that I am not in a high risk category, including: diabetes, cardiovascular disease,
hypertension, lung diseases including moderate to severe asthma, being immunocompromised, having
active malignancy, or over age 65.
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 I am not currently positive for the novel coronavirus.
I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus.
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.
In the last 14 days, I have not been in contact with 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 understand that Alberta Health Services has asked individuals to maintain physical distancing of at least 2 metres (6 feet) and I agree to follow this while moving within the office while there.
I understand that it is not possible to maintain physical distancing during dental procedures.
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 water spray which is one way that the novel
coronavirus can spread. The ultra-fine nature of the spray 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 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 May 4 to 14, 2020
Guidelines that only urgent and emergent dental is allowed.
I confirm I am seeking treatment for an urgent or an emergent condition that meets these criteria.
I verify the information I have provided on this form is truthful and accurate. I knowingly and
willingly consent to have orthodontic emergency or urgent dental treatment completed
during the COVID-19 pandemic.