Now Open Above Blush Lane in Marda Loop SW

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 submission of COVID-19 Patient 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.




I understand and agree

I understand and agree

I do NOT have a fever > 38°CI do NOT have a new cough or worsening chronic coughI do NOT have a sore throat or painful swallowingI do NOT have new or worsening shortness of breathI do NOT have difficulty breathingI do NOT have flu-like symptomsI do NOT have a runny noseI do NOT have Loss of smell or taste

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

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

The Team at Odeon Dental looks forward to seeing you at your next appointment!

We invite you to call Odeon Dental at (403) 764-6510 to set up a new patient consultation appointment today!

Providing Family, Restorative, Cosmetic, Family & General Dentistry to Marda Loop, Garrison Woods, Altadore, South Calgary, CFB Currie, Rutland Park, Killarney, Bankview, Scarborough, Lower Mount Royal, Upper Mount Royal, Elbow Park, and surrounding SW Calgary Areas.