WE REQUIRE THIS FORM 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 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.




I understand and agree

I understand and agree

I do NOT have a fever > 38°CI do NOT have a new cough or worsening chronic coughI do NOT have a sore throat or painful swallowingI do NOT have new or worsening shortness of breathI do NOT have difficulty breathingI do NOT have flu-like symptomsI do NOT have a runny noseI do NOT have Loss of smell or taste

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.I fall into a high risk categories and my dentist and I have discussed the risks, and I have agreed to proceed with treatment.


I understand and agree

I understand and agree
Please note: Any individual who has gone in for testing on their own volition as an asymptomatic individual does not need to indicate that.

I understand and agree

I understand and agree

I understand and agree

I understand and agree
OR

I understand and agree


I understand and agree


SIGNATURE OF PATIENT

Thank you from the Team at Welcome Smile Dental!

For More Information Please Call Us at 403-261-8855 or Request An Appointment