Patient Covid-19 Consent

Patient name:*

If you have any of these symptoms, check the box below:

Fever > 38°C

Cough

Sore throat

Shortness of breath

Runny Nose

I confirm that to my knowledge 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.*

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 the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to dental treatment.*

SIGNATURE OF PATIENT/GUARDIAN*

Printed Name*

Date*