COVID-19 Pandemic Support Team Member Daily Consent Form

  • Date Format: MM slash DD slash YYYY
  • I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

    I understand that dental procedures create water spray, which is one way that the novel coronavirus can spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus.

    I understand that due to the frequency of visits of other team members, dentists and dental patients, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have an elevated risk of contracting the novel coronavirus simply by being in a dental office.

  • I confirm that I am not presenting any of the following symptoms of COVOID-19 identified by Provincial Health Services:

  • I confirm that I have considered if I am in high risk category (e.g. diabetes, heart disease, lung diseases, ≥60 years of age) and have chosen to work.

  • I confirm that I am not currently positive for the novel coronavirus.

  • I confirm that I am not waiting for results of a laboratory test for the novel coronavirus.