Please complete the following patient screening and consent form. Please specify who is completing this form and enter your name or the Patients name if completing on their behalf. This is a pre-screening only. Upon arrival at the office, you will be asked to sanitize your hands, have your temperature taken, as well as answer these questions again.

As per current Alberta Health Services Protocol, only patients are allowed in the office. However, if a parent/guardian is needed, please complete a screening form for yourself, and follow the same protocol. Otherwise, please remain in your vehicle.

Patient Information

Who is Completing this Form? *

Patient

Parent/Guardian/Other on behalf of Patient

Parent/Guardian/Other for themselves (Non-Patient attending)

Name: (If filling out on behalf of a Patient provide their name) *

if Parent/Guardian/Other has been selected please also provide:

Relationship to Patient:

Preferred Contact Method? *

Phone

Other

Please provide the information for your chosen preferred contact method:

Phone:

E-Mail:

Other:

Screening Questions

1. Have you tested positive for COVID-19 in the past 14 days? Or are you still awaiting COVID test results? *

Yes

2. Do you have a fever or have felt hot or feverish anytime in the last 10 days? *

Yes

3. Do you have any of the core symptoms: *

New or worsening cough?
New or worsening shortness of breath?
Sore throat or painful swallowing?
Runny nose?

Yes

4. Have you experienced a recent loss of smell or taste? *

Yes

5. A) 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

5. B) Have you been in contact with anyone awaiting results from a COVID test? *

Yes

6. Have you returned from travel outside of Canada in the last 14 days? *

Yes

7. Have you returned from travel within Canada from a location known to be affected with COVID-19 in the last 14 days? *

Yes

8. Is your workplace considered high risk? *

Healthcare workers who have worn appropriate PPE may answer No

Yes

9. Are you over age 65? *

Yes

10. Do you have any of the following: *

Heart disease
Lung disease
Kidney disease
Diabetes
Any other auto-immune disorder?

Yes

If you have answered YES to any questions 1 – 9, please call our office to discuss, and we can assess any risks.

Consent

Please consent by accepting both acknowledgments listed below, providing todays date, and hitting submit.

Acknowledgment: *

I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

Acknowledgment: *

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to my scheduled appointment with Dr. Neal Palmer/Palmer Orthodontics.

Today's Date *

Leave Blank

Patient Screening and Consent

Patient Information

Screening Questions

Consent