COVID-19 Pandemic Dental Treatment Consent Form
Patient name:
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First Name
Last Name
Email:
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example@example.com
I confirm that, to my knowledge, I am not currently positive for COVID-19 and am required to isolate in accordance with Saskatchewan provincial health guidelines.
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Confirm
I confirm that I am not waiting for results of a laboratory test for COVID-19.
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Confirm
For patients over 18 years of age, I confirm that I am not presenting any of the following core symptoms of COVID-19 as identified by Saskatchewan Health Services:
I do not have a fever > 38°C
I do not have a new cough or worsening chronic cough
I do not have a sore throat or painful swallowing
I do not have a new or worsening shortness of breath
I do not have difficulty breathing
I do not have flu-like symptoms (including nausea/vomiting and fatigue)
I do not have a runny nose
I do not have an unexplained rash
I have not experienced a recent loss of smell or taste
For patients under 18 years of age, I (as a parent or guardian) confirm that they are not presenting any of the following core symptoms of COVID-19 as identified by Saskatchewan Health Services:
I do not have a fever > 38°C
I do not have a new cough or worsening chronic cough
I do not have a sore throat or painful swallowing
I do not have a new or worsening shortness of breath
I do not have difficulty breathing
I do not have flu-like symptoms (including nausea/vomiting and fatigue)
I do not have a runny nose
I do not have an unexplained rash
I have not experienced a recent loss of smell or taste
I confirm that, to my knowledge, I have not come into contact with someone who has tested positive for COVID-19 and am required to isolate in accordance with Saskatchewan provincial health guidelines.
Confirm
I confirm that I am not currently subject to a public health or government-mandated quarantine or period of self-isolation.
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Confirm
List of Dental Treatment Required:
PLEASE READ CAREFULLY:
I verify the information I have provided on this form is truthful and accurate. I acknowledge that being in a dental clinic increases my risk of contracting COVID-19. I knowingly and willingly consent to have all required and/or recommended dental treatment completed during the COVID-19 pandemic. Please use your mouse or finger to sign below.
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(Signature)
Printed Name:
*
First Name
Last Name
Date:
*
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Month
-
Day
Year
Date
Submit
Should be Empty: