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Meet Us
Dental Services
New Patients
Contact Us
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407 2nd St. SW
+1(403) 263-1346
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Meet Us
Dental Services
New Patients
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Thank you for booking an appointment.
Please fill in this covid19 information form. Without this form we will not be able to book your appointment.
Patient name:
*
Date
*
I understand that due to frequency of visits of other dental patients, the characteristics of coronavirus and dental procedures that I have an elevated risk of contracting the coronavirus simply by being in the dental office. I accept the risk associated with dental treatment.
Do you have a fever or have felt hot or feverish anytime in the last 10 days?
*
Yes
No
Do you have any of these symptoms: New or worsening cough? New or worsening shortness of breath? Difficulty breathing? Sore throat or painful swallowing? Runny nose?
*
Yes
No
Please list symptoms
Have you experienced a recent loss of smell or taste?
*
Yes
No
Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?
*
Yes
No
Have you travelled outside of Canada in the last 14 days?
*
Yes
No
Is your workplace considered high risk?
*
Yes
No
If you are a healthcare worker, did you use PPE when treating patients?
*
Yes
No
N/A
Are you over the age of 65?
*
Yes
No
Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?
*
Yes
No
Which conditions do you have?
Heart disease
Lung disease
Kidney disease,
Diabetes
Auto-immune disorders
Are you waiting for test results for COVID-19?
*
Yes
No
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