Please complete the following patient screening and consent form. Identify, patient name, age, and who completed the form. 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.

Please be advised, that at the present time, only patients are allowed in the office, (if a parent/guardian is needed, they will follow the same protocol. Otherwise, please wait in your vehicle or just outside of our office.

Patient/Guardian Name *

Patient/Guardian Age *

Who Completed Form *

Patient

Other

Contact Method *

Phone

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

Yes

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

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

Yes

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

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

Yes

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

Yes

Do you or a member of your home work in a high risk environment? *

Yes

Are you over age 65? *

Yes

Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any other auto-immune disorder? *

Yes

CONSENT *

If you have answered YES to any questions 1 – 7, please call our office to discuss, and we can assess any risks.

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.

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.

Please consent by typing full name of patient if over 18.

Or, consenting parent/guardian if under 18.

4 Digit Year of Birth of Patient *

Today's Date *

Leave Blank

Effective May 14, the Alberta Government and with protocol from The Alberta Dental Association and College, we are now able to return to a full provision of services. Please complete the COVID screening form for each person entering the office. This form must be completed each time you come for an appointment.

Prescreening & Consent Form

Patient Screening and Consent

Covid 19 Relaunch & Guidelines