All Staff Are Required to Complete This Consent Form Prior to Each Shift

COVID-19 Staff consent is required 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 staff consent form in order for patients and staff to attend appointments.



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.

    *Staff Member Name:

    *Staff Member Email:

    I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Alberta Health Services:

    Please note: Any individual who has gone in for testing on their own volition as an asymptomatic individual does not need to indicate that.

    I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to work on all dental treatment patients for, during the COVID-19 pandemic. I understand that I may revoke this consent to provide dental treatment or assist with the provision of dental treatment at any time during the day. This means that I may change my mind.

    AM Temperature:


    Printed Name

    Date Signed

    Thank you for being an integral part of the Acora Dental Team!