COVID-19 Pandemic Dental Treatment Consent Form
Completion of this form is required prior to any member of the public entering the clinic to help us ensure we keep everyone safe and continue our duty to flatten the curve.
Please complete this form on THE DAY OF your appointment, BEFORE YOU ARRIVE
Prior to entering the clinic, please ensure you have read the appointment reminder email to familiarize yourself and to adhere to the social distancing practices implemented by TREC Dental and any of its subsidiaries.
Which clinic are you visiting?
4th Street Dental
Auburn Bay Dental
Bridgeland Crossings Dental
Cranston Market Dental
Distinctive Dental Studio
Mahogany Village Dental
New Brighton Dental
Nolan Hill Dental
Royal Oak Dental
Sage Meadows Dental
University District Dental
Are you (or anyone with you today) currently experiencing any of the following symptoms of COVID-19 identified by Alberta Health Services :
Fever (> 38 degrees or subjective fever)
New onset of cough or worsening of chronic cough
New or worsening difficulty breathing (shortness of breath)
Sore throat or hoarse voice
Feeling unwell, fatigue or severe exhaustion
Nausea, vomiting or diarrhea for more than 24 hours
Unexplained loss of appetite
Loss of smell or taste
I do not have any of the above mentioned symptoms
Within the past 14 days, have you received a positive diagnosis for COVID-19?
Are you waiting for the results of a laboratory test for COVID-19.
Within the past 14 days, have you (or anyone in your home) traveled outside of Canada?
Within the past 14 days, have you been identified as a contact of someone who has tested positive for COVID-19 or been asked to self-isolate by Alberta Health, the Communicable Disease Control, or any other governmental health agency?
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This form was created inside of TREC Dental.