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

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

Please provide the information for your chosen preferred contact method:

Screening Questions

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

Healthcare workers who have worn appropriate PPE may answer No

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

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


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