WE REQUIRE THIS FORM BE COMPLETED 24 HOURS PRIOR TO YOUR NEXT APPOINTMENT

To ensure the health and safety of both our patients and staff during the COVID-19 pandemic, we require submission of consent in order for patients and staff to attend appointments.

All patients are required to review and submit a consent form prior to coming in for their appointment.

PLEASE COMPLETE THE PATIENT CONSENT FORM BELOW:

* Indicates Required – Please note all statements below must be confirmed and checked prior to form submission.

CMOH Order 05-2020 legally obligates any person who has the following cough, fever, shortness of breath, runny nose, or sore throat (that is not related to a pre-existing illness or health condition) to be in isolation (quarantine) for 10 days from the start of symptoms, or until symptoms resolve, whichever takes longer. If they are exhibiting any of these symptoms, it is suggested they complete the COVID-19 Self-Assessment online tool to determine if they should be tested.




    I understand and agree

    I understand and agree

    I confirm I know that there are categories of people who are considered to be high risk. I understand the high risk category factors are being 65 years of age or older, heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder.I fall into a high risk categories and my dentist and I have discussed the risks, and I have agreed to proceed with treatment.


    I understand and agree

    I understand and agree


    Travel During the Pandemic



    I understand and agree

    I understand and agree

    I understand and agree

    I understand and agree

    I understand and agree
    Or

    I understand and agree


    I understand and agree


    SIGNATURE OF PATIENT

    Thank you from the Team at West Calgary Periodontics!

    Alternatively, please complete & submit the COVID form below!

    The form can be downloaded and submitted by email.

    Contact Us

    Quick Contact Form

    Please Do Not Use This Form To Cancel Or Reschedule An Existing Appointment

      Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information. Please review our privacy policy and website terms of use prior to submitting your form request.

      Opening Hours

      Monday: Closed

      Tuesday to Friday: 8:00am to 4:00pm

      Weekends & Statutory Holidays: Closed

      Parking

      Plenty of Free Onsite Parking

      Accessibility

      West 85th Professional Building is Wheelchair Accessible including Elevator & Washrooms

      Call us at (403) 727-5307 to schedule your appointment today!
      No referral is necessary.