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.
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First Name *
Last Name *
Which clinic are you visiting? *
Are you (or anyone with you today) currently experiencing any of the following symptoms of COVID-19 identified by Alberta Health Services : *
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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