COVID-19 Staff Consent

All Staff are Required to Complete
This Consent Form Prior to Each Shift

To ensure the health and safety of both our patients and staff during the COVID-19 pandemic, we require submission of a COVID-19 staff consent form in order for patients and staff to attend appointments.

PLEASE COMPLETE THE STAFF 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.

    *Staff Member Name:

    *Staff Member Email:

    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. (Initial)

    I understand that certain dental procedures create aerosols which are one way that the novel coronavirus can spread. (Initial)

    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. (Initial)

    I have received training on the occupational health and safety controls that have been implemented at my workplace to minimize the risk of COVID_19 transmission. (Initial)

    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. (Initial)

    I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Alberta Health Services:

    Fever > 38°C (Initial)
    Cough (Initial)
    Sore Throat (Initial)
    Shortness of Breath (Initial)
    Difficulty Breathing (Initial)
    Flu-like symptoms (Initial)
    Flu-like symptoms (Initial)
    Runny Nose (Initial)

    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. (Initial)

    I confirm that I am not currently positive for the novel coronavirus. (Initial)

    I confirm I am not waiting for the results of a laboratory test for the novel coronavirus that was ordered due to contact tracing or because I had identified risk factors. (Initial)

    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 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. (Initial)

    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. (Initial)

    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. (Initial)

    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. (Initial)

    I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to work on all dental treatment patients for 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 OF PATIENT

    Printed Name Date

    Thank you for being an integral part of the
    Tooth Suite Family Dentistry Team!

    Disclaimer

    Dr. Marianne Stelmaschuk, Dr. Sonia Thibault, Dr. Gladys NewLove-Heide are Lloydminster General Dentists. They are not specialists in Cosmetic or Family Dentistry. Cosmetic and Family Dentistry are not specialties recognized by the Alberta Dental Association & College (ADA&C). Our general dentists provide Cosmetic and Family Dental procedures such as Porcelain Veneers, Dental Crowns, Invisalign, and Teeth Whitening as part of their General Dentistry license. As Lloydminster Family Dentists, we provide General Dental procedures for all ages within the family. Dr. Prabhjot Singh is a licensed Oral and Maxillofacial surgeon and can offer Oral Maxillofacial specialty services as part of his license.