COVID-19 Pandemic Support Staff Daily Consent Form
First Name:
Last Name:
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.
YesNo
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.
YesNo
I understand that certain dental procedures create aerosols which are one way that the novel coronavirus can spread.
YesNo
I understand that due to the frequency of visits of other staff, dentists and dental patients, the characteristics of the novel coronavirus, the characteristics of dental procedures and that many dental procedures generate aerosols that I have an elevated risk of contracting the novel coronavirus simply by being in a dental office.
YesNo
I have been made aware of the Alberta Dental Association and College’s Expectations and Pathway for Patient Care during the COVID-19 Pandemic. I confirm that I have read and understand them.
I confirm that I am NOT presenting any of the following symptoms of COVID-19 identified by Alberta Health Services:
YesNo
Fever > 38°C
YesNo
New or worsening chronic cough
YesNo
Sore throat or painful swallowing
YesNo
New or worsening shortness of breath
YesNo
Difficulty Breathing
YesNo
Flu-like symptoms
YesNo
Runny Nose
YesNo
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. If I am in one of these categories, 
I have chosen to work knowing the risk to my health if I develop COVID-19.
YesNo
I confirm that to my knowledge I am not currently positive for the novel coronavirus.
YesNo
I confirm that I am not waiting for results of a laboratory test for the novel coronavirus.
YesNo
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.
YesNo
I understand that any travel from any country outside of Canada, including travel by car, air, bus, boat 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.
YesNo
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 provide or assist with dental treatment.
YesNo
I verify that I have not been identified as a close contact of a confirmed case of someone who has tested positive for novel coronavirus and/or been asked to self-isolate by Alberta Health, the Communicable Disease Control or any other governmental health agency.

YesNo

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to work on (YYYY-MM-DD) during the COVID-19 pandemic. I understand that I may revoke this consent to provide dental treatment or assist with the provision of dental treatment at any time during the day. This means that I may change my mind.
AM Temperature:
PM Temperature:
Signature
Date
(YYYY-MM-DD)
Printed Name