Calgary, Alberta / 403-279-5171

Patient Profile & Registration Forms

COVID-19 Pandemic Dental Treatment Consent Form

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.

**Your temperature will be taken when you arrive at the clinic and recorded in your file**

Yes
No
Yes
No
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No
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No
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No
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No

OR

Yes
No

Please note: Any individual who has gone in for testing on their own volition as an asymptomatic individual does not need to indicate that.

Yes
No
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No
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OR

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No

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the dental treatment completed during the COVID-19 pandemic.

Our Dental Services

Dental Exams & Cleanings

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FAMILY DENTISTRY

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Emergency Dental Care

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Information

Glenmore Family Dental Care
140-4000 Glenmore Court SE
Calgary, AB

T2C 5R8

Phone: 403-279-5171

Email: gfdc.nicole@shaw.ca

Hours

Monday 10:30 AM - 07:00 PM

Tuesday 10:30 AM - 07:00 PM

Wednesday 07:00 AM - 03:30 PM

Thursday 07:00 AM - 03:30 PM

Friday 07:00 AM - 03:30 PM

Saturday Closed

Sunday Closed

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