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    COVID-19 Patient Consent Form

    WE REQUIRE THIS COMPLETED PRIOR TO YOUR NEXT APPOINTMENT

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

    All patients are required to review and submit a 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.











      Patients who are well but who have a sick family member at home should postpone elective treatment.





      SIGNATURE OF PATIENT


      Thank you from the Team at Chinook Smiles!