Same Day Emergencies COVID-19 Patient Consent Form

COVID-19 Pre-Screening Form

Measures we are taking to keep everyone safe:

  • Our front door will remain locked and for appointment only
  • We ask that you call us upon arrival to be COVID-19 screened prior to entering the clinic, in addition to the below pre-screening form
  • Upon entering the clinic, you’ll be given a mask if you don’t have one
  • If you’re not feeling well, please do not come to the clinic, call us at 403-282-9141 and we’ll be happy to reschedule your appointment
  • Only the Patient, or Patient and one Guardian/Caregiver will be given access to the clinic, up to a maximum of 2 individuals (including the Patient).
  • Our team will be wearing enhanced PPE (exceeding the standards required)
  • Large plexiglass sneeze guard at reception
  • 100% mask compliance
  • Continued strict sterilization monitoring

If you have an upcoming appointment, please fill out the COVID-19 Pre-Screening Form below to help us help you!


COVID-19 Pre-Screening Form

Name(Required)
Do you have any of the following symptoms?(Required)
Do you have any of the following?(Required)