WE REQUIRE THIS FORM TO BE COMPLETED PRIOR TO YOUR NEXT DENTAL APPOINTMENT!

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

All patients are required to review and submit a COVID-19 patient consent form prior to coming in for their next dental 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 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


    Travel During the Pandemic



    I understand and agree

    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 Main Street Dental Airdrie!

    We Invite You To
    Call Us At (403) 948-7945 To Book Your Appointment Today!

    Monday: 7:40 am to 3:30 pm
    Tuesday: 7:40 am to 3:30 pm
    Wednesday: 7:40 am to 8:00 pm
    Thursday: 7:40 am to 8:00 pm
    Friday: 8:00 am to 4:00 pm
    Saturday: By Appointment Only
    Sundays: Closed
    Statutory Holidays: Closed