Dr. Claude Boutin - COVID-19 Supplemental Health Questionnaire

This form is for (Please list full names of everyone coming into the clinic):
Please click Yes/No at the end of the following questions:

Have you, your child, or others accompanying you to today's appointment travelled outside of Canada within the last 14 days?
Are you, your child, or others accompanying you to today's appointment feeling sick with any one of the following symptoms: fever, flu-like symptoms, sore throat, new or worsening cough, new or worsening runny nose or sneezing, shortness of breath and/or trouble breathing, tightness/pain in the chest?
Have you, your child, or others accompanying you to today's appointment been exposed to anyone who is known to have Covid-19 or may be ill with Covid-19?

Have you, your child, or others accompanying you to today’s appointment been asked to isolate by Alberta Health Services (AHS)?

Acquiring any infection in our office is unlikely because we continue to follow provincial and federal regulations which require universal personal protection and disinfection protocols to limit transmission of all diseases as we have always done.
I knowingly and willingly consent to undergo dental treatment during the COVID-19 pandemic.
Patient First Name:
MI:
Last Name:
Parent/Guardian First Name:
MI:
Last Name:
Relationship to Patient:
Patient/Parent/Guardian Signature:
Date: