Dental Treatment Consent Form

Please Fill Out the COVID-19 Pandemic Dental Treatment Consent Form

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

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

LIST of DENTAL TREATMENT

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.

Sundance Dental Clinic

70 SHAWVILLE BLVD SE, UNIT 134

Calgary, AB T2Y 2Z3

Hours

Monday: 10:30am – 6pm
Tuesday: 7am – 6pm
Wednesday: 7am – 6pm
Thursday: 10am – 6pm
Friday: 7am – 1pm
Saturday: 8:30am – 4pm
Sunday – Closed
Closed for long weekends

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