Same Day Emergencies COVID-19 Patient Consent Form

COVID-19 – Patient Consent Form

We Require This Form to Be Completed Prior to Your Next 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.


* 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:

    Or is someone else filling this form out for the patient? If so, who

    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
    • Runny nose (Over 18 Only)

    Please Select ONE:

    Travel During the Pandemic

    Please Select ONE:

    Please Select ONE:


    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.



    Printed Name
    Date Signed

    Thank you from the Team at 16TH AVENUE DENTAL!

    Our dental practice always welcomes new patients. No referral is required!