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Covid-19 Staff Daily Consent Form

New Patient Form Additional Adult

Patient Information (Confidential). All fields are mandatory, please enter n/a if they do not apply. Name of Person on the original 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.
  • I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Alberta Health Services:
  • Please note: Any individual who has gone in for testing on their own volition as an asymptomatic individual does not need to indicate that.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY