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About Us
- Meet Your NW Calgary Dentist
- Your Dental Team
Why 16th Avenue Dental?
- COVID-19 Protocols
- Giving Back
Our Services
Blog
Contact Us

COVID-19 Pre-Screening Form GET DIRECTIONS

cosmetic dentistry

Do Porcelain Veneers Stain?

Cosmetic Dentistry |3 min read

Do Porcelain Veneers Stain?

by Dr. My Le | Jul 29, 2021

You’ve probably heard of veneers. Maybe you’re thinking of getting them. So many people are getting porcelain veneers these days. Why is that? Porcelain has some incredible qualities that make this type of veneer stand out from the rest. They’re radiant and...

How Long Does Teeth Whitening Last?

Cosmetic Dentistry |6 min read

How Long Does Teeth Whitening Last?

by Dr. My Le | Dec 18, 2020

If you’ve dreamed of getting a brighter smile, then you may have wondered, “How long does teeth whitening last?” The quick answer: The effects of teeth whitening may last for a few months or a few years, but this depends on the method of whitening...

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16th Avenue Dental
824 16 Avenue NW
Calgary, AB T2M 0J9
Phone: 403-282-9141
Email: info@16thavenuedental.ca

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COVID-19 Pre-Screening Form

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COVID-19 Patient Consent Form

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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.*

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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 the novel coronavirus simply by being in a dental office.*

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I consent to having my temperature taken upon arrival to my scheduled appointment. If my recorded temperature is higher than 38°C, my appointment will be rescheduled.*

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For All Patients - I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Alberta Health Services: Fever > 38°C, Cough, Sore Throat, Shortness of breath, or Runny nose*

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I confirm I know that there are categories of people who are considered to be high risk. I understand the high-risk category factors are being 65 years of age or older, heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder.*

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If high-risk, please specify cateory*

I confirm to my knowledge that I am not currently positive for the novel coronavirus.*

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I confirm I am not waiting for results of a laboratory test for the novel coronavirus.*

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I confirm that I understand that if I have to quarantine or have tested positive for COVID-19 I cannot enter a healthcare facility for 10 days or until my symptoms have resolved, whichever is longer.*

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If you have had COVID-19 in the last month or have answered “No” to any of the above statements, please immediately call our office at 403-282-9141 so we determine if we need to reschedule or keep your appointment with us.

TRAVEL DURING THE PANDEMIC

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.*

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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.*

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I understand that 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.*

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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.*

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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.*

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If you have had COVID-19 in the last month or have answered “No” to any of the above statements, please immediately call our office at 403-282-9141 so we determine if we need to reschedule or keep your appointment with us.

LIST OF DENTAL TREATMENT

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By signing below, I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above-listed dental treatment completed during the COVID-19 pandemic.

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Disclaimer: Dr. My Le is a NW Calgary general dentist. She is not a specialist in cosmetic or family dentistry. Cosmetic and family dentistry are not specialties recognized by the Alberta Dental Association & College (ADA&C). General dentists can provide cosmetic dental procedures such as porcelain veneers, dental implants, dental braces, and teeth whitening as part of their general dentistry license. As a NW Calgary family dentist, Dr. My Le provides general dental procedures for all ages within the family.

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