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.
*By typing your name below, you are electronically signing and certifying that you are in understanding of the above section 1 statements
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.
*By typing your name below, you are electronically signing and certifying that you are in understanding of the above section 2 statements
Section 3
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 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.
*By typing your name below, you are electronically signing and certifying that you are in understanding of the above section 3 statements