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Due to the COVID-19 pandemic, Alberta Health Services and The Alberta Dental Association & College require all patients to complete a health pre-screening form before entering our office for dental treatment. Click here to fill out our online form.

Patient Pre-Screening

COVID-19 Pandemic Dental Treatment Consent Form

Patient ( )
Phone
Email
Other
Fever > 38℃ anytime in the last 10 days
Cough
Sore Throat /Painful Swallowing
Shortness of Breath
Difficulty Breathing
Flu-Like Symptoms
Runny Nose
None of the above
YES
NO
YES
NO
YES
NO
YES
NO
Heart disease
Lung disease
Kidney disease
Diabetes
Any auto-immune disorder
None of the above
YES ( )
NO ( )
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