Pre Screening

Name *

First

Last

Mobile Number *

Do you have any of the below symptoms: *

Fever (greater than 38.0C)
Cough
Shortness of Breath / Difficulty Breathing
Sore throat
Runny Nose
None of Above

Have you, or anyone in your household travelled outside of Canada in the last 14 days? *

Have you, or anyone in your household been in contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID19? *

Are you currently being investigated as a suspect case of COVID-19? *

Have you tested positive for COVID-19 within the last 10 days? *

Ask that they stay home and complete Alberta’s online COVID-19 selfassessment *

Do you understand that due to the frequency of visits of other dental patients, the characteristics of COVID-19 and the characteristics of dental procedures, that you have an elevated risk of contracting COVID-19 simply by being in a dental office?