I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Alberta Health Services
I confirm that to my knowledge I am not currently positive for nor waiting for 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, boat or train in the past 14 days.
I verify that I have not been identified as a contact of 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 verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above listed orthodontic, dental treatment or attend with a patient having treatment completed during the COVID-19 pandemic and consent to the electronic use of this form, via email.
*I certify that I am the parent or legal guardian of the above minor and confirm that the information I entered is accurate and true. *I am at least 18 years old and I have read and agree to the terms of the above agreement.
By typing your name below and initials above, you are electronically signing, initialing and certifying this consent document just as if it were paper.