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New Patients
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407 2nd St. SW
+1(403) 263-1346
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Patient temperature
Patient temperature <38°C at appointment
Patient temperature >38°C
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
If yes please list:
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
Are you waiting for test results for COVID-19?
YES
NO
SUBMIT
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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