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Patient Wellness Form

We're implementing new procedures in accordance with Alberta Health Services' guidelines and strict COVID-19 countermeasures to ensure the health and safety of our patients, our team and the wider community. Please fill out the form below to help us help you!

*All fields with asterisks are mandatory.

Name*

Email*

1. Are you currently in Self Isolation?*
YesNo

2. Have you travelled outside Canada in the last 14 days?*
YesNo

3. Have you had close contact** with a confirmed or probable case of COVID-19 in the last 14 days?*
YesNo

4. Have you had close contact** with a person with acute respiratory illness who has travelled anywhere outside of Canada within the last 14 days before their illness?*
YesNo

5. Have you had laboratory exposure to biological material (eg. Primary clinical specimens, virus culture isolates) known to contain COVID-19 virus?*
YesNo

6. Are you experiencing any of the following symptoms? (Please check all that apply.)*

NO SYMPTOMSFeverDry coughShortness of breathFatigue/ LethargySore throatRunny noseNasal CongestionSneezingBody aches and pains

**A close contact is defined as a person who:

Provided care for the individual, including healthcare workers, family members or other caregivers, or who had other similar close physical contact with the person without consistent and appropriate use of personal protective equipment.
Lived with or otherwise had close prolonged contact (with 2 metres) with the person while the person was infectious.
Had direct contact with infectious bodily fluids of the person (eg. Was coughed or sneezed on) while not wearing recommended personal protective equipment.

*I have read all of the above statements and certify that the information submitted in this application is true and correct to the best of my knowledge.

Signature*

Date*

At Midtown Dental our leading-edge practitioners are dedicated to delivering the ultimate experience in service,convenience and quality of dental care.

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DENTAL SERVICES

General Services
Cosmetic and Orthodontics
Surgical and Sedation
Sleep Apnea Testing

LOCATION

Suite 103, 320 23rd Ave SW
Calgary, AB T2S 0J2

HOURS

Monday - Friday
7:30 am - 4:00 pm

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