Our goal at Altitude Dental is to provide a safe environment for our patients and staff and to advance the safety of our local Community. The COVID-19 virus is a serious and highly contagious disease. The World Health Organization has classified it as a pandemic. You could contract COVID-19 from a variety of sources. Our clinic is taking every precaution to limit the risk of transmission between patients, staff and our dentist. Despite these efforts, you understand that there is a still a risk of contracting COVID-19 within the dental clinic. Specifically, dental procedures can create water spray (called aerosols) which is a possible source of transmission of the virus. As a result, out clinic is taking extra precautions such as limiting aerosol generating procedures, modified sanitation techniques and the use of personal protective equipment. I acknowledge that my Dentist has informed me about COVID-19 and risk of transmission during my visit to Dental clinic. Dentist has also adequately explained to me the risks with delaying my dental treatment as such I wish to proceed with the proposed treatment. I confirm that I have read and understood this Waiver. I understood and accept that there is a risk of contracting the COVID-19 virus in the dental office or with dental treatment in general. I have read and understand the information stated above.Print Name of Patient Patient/Parent or Guardian Signature* Date DD slash MM slash YYYY Patient Name Date of Appointment DD slash MM slash YYYY Temperature upon Arrival (To be taken on site by clinic staff) All patients are asked to answer the following questions before their appointment and prior to commencing any recommended dental procedures. You acknowledge that certain dental procedures create aerosols which are one way that the novel corona virus ca spread. The following questions will help our clinical team ensure a safe environment for both patients and staff.I have not tested positive for COVID-19 nor am I awaiting any test results for COVID-19 True False I have not been in contact with any person who has been diagnosed with COVID-19 True False I have not been advised by my physician or provincial health authority to individually quarantine due to a possible exposure to COVID-19 True False I have not recently (within 21 days) had any of the following symptoms: True False Fever (temperature above 37 degree Celsius) Repetitive or chronic coughing Shortness of breath or difficulties breathing Sore throat or painful swallowing A loss of taste or smell General or specific muscle pain not normally experienced General flu like symptoms including a runny nose, upset stomach, diarrhea or headache I have not travelled in the last 14 days to any areas significantly impacted by COVID-19 True False I confirm that I know there are categories of people who are considered to be at 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 autoimmune disorder. If I am in one of these categories I have chosen to proceed with my appointment knowing the risk to my health if I develop COVID-19.* Confirmed If the patient is not able to affirm any of the questions above a consultation with your Dentist will need to occur prior to the commencement of any appointments.Patient/Parents/Guardian Signature*
