COVID-19 Online Patient Consent Form

We Require This Form to Be Completed the Day of Your Appointment

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.

All patients are required to review and submit a consent form prior to coming in for their next dental appointment.

PLEASE COMPLETE THE PATIENT CONSENT FORM BELOW:

* Required

CMOH Order 05-2020 legally obligates any person who has the following cough, fever, shortness of breath, runny nose, or sore throat (that is not related to a pre-existing illness or health condition) to be in isolation (quarantine) for 10 days from the start of symptoms, or until symptoms resolve, whichever takes longer. If they are exhibiting any of these symptoms, it is suggested they complete the COVID-19 Self-Assessment online tool to determine if they should be tested.

    *Patient Name:

    *Patient E-mail:

    Have you tested positive for COVID-19 in the past 14 days OR are you waiting for a result of a COVID- 19 test?
    YesNo

    Have you been a household contact of a case of Covid-19 in the last 14 days and are NOT fully immunized?
    YesNo

    Have you travelled out of Canada in the last 14 days and are NOT fully immunized?
    YesNo

    Do you have any NEW onset (or worsening) of the following symptoms:Not related to other known causes or conditions

    • - Fever YesNo
    • - Cough YesNo
    • - Shortness of Breath YesNo
    • - Runny Nose YesNo
    • - Sore throat YesNo
    • - Chills YesNo
    • - Painful Swallowing YesNo
    • - Nasal congestion YesNo
    • - Feeling unwell/fatigued YesNo
    • - Nausea, vomiting or diarrhea or unexplained loss of appetite YesNo
    • - Loss of sense of smell or taste YesNo
    • - Muscle or joint pain or aches — not related to arthritis YesNo
    • - Headache YesNo
    • - Conjunctivitis (also known as pink eye) YesNo

    Patient Risk and Vulnerability

    Do you have any of the following risk factors?

    • - Over the Age of 65? YesNo
    • - Heart Disease? YesNo
    • - Lung Disease YesNo
    • - Kidney Disease YesNo
    • - Diabetes YesNo
    • - Immunocompromised Status YesNo

    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 COVID-19 by being in the dental office.

    I understand the 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 receive dental treatment.

    SIGNATURE OF PATIENT

    Printed Name

    Date Signed

    Thank you from the Team at Northern Hills Dental!

    Our Practice Always Welcomes
    New Patients – No Referral Is Required!

    CONTACT US

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      Our Address

      40 Panatella Blvd. NW
      Calgary, Alberta
      T3K 6K7
      (403) 532-0711
      (403) 532-0703

      Our Hours

      Monday: 7:00 am to 8:00 pm

      Tuesday: 7:00 am to 8:00 pm

      Wednesday: 7:00 am to 8:00 pm

      Thursday: 7:00 am to 8:00 pm

      Friday: 8:00 am to 4:00 pm

      Saturday: 9:00 am to 4:00 pm

      Sunday:9:00 am to 4:00 pm (select)

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