Section 1

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 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 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 Guidelines that under the current pandemic dental care is permitted.

Section 2

I confirm that I am not presenting any of the following symptoms of COVOID-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
• Runny nose

I confirm that I have considered if I am in high risk category (e.g. diabetes, heart disease, lung diseases, ≥60 years of age) 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.

Section 3

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 social 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 dental treatment patients on the day this document is dated 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.