• I confirm that I am not presenting any of the following symptoms of COVOID-19 identified by Alberta Health Services:

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

  • Date Format: MM slash DD slash YYYY