Patient Screening Form

To reduce the risks of transmission and ensure the safety of our dentist, staff, or other patients in the practice, we will be asking the following questions prior your appointment with us.

Do you, your child, others accompanying you to today's appointment or anyone you have recently been in contact with having any of the following symptoms?

Patient Name *

Do you have a fever or have felt hot or feverish anytime in the last two weeks? *

Yes
No

Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? Sneezing? Post-nasal drip? *

Yes
No

Have you experienced a recent loss of smell or taste? *

Yes
No

Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19? *

Yes
No

Have you travelled outside of Canada and are required to quarantine for 14 days? *

Yes
No

Is your workplace considered high risk? *

Yes
No

COVID-19 DENTAL RISK ACKNOWLEDGEMENT FORM:

Please read the patient acknowledgement questions and check all areas indicated.

I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. For this reason, it is recommended to stay home and avoid close contact with other people when at all possible *

I Agree

I understand the federal and provincial governments have asked individuals to maintain social distancing of a least 2 metres (6 feet) and I recognize it is not possible to maintain this distance while receiving dental treatment *

I Agree

I understand that it is possible that oral surgery/dental procedures can create water and/or blood spray, which may be one way that the novel coronavirus can spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus. *

I Agree

I understand that due to the visits of other patients, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have an elevated risk of contracting AND SPREADING the novel coronavirus simply by being in the dental office. *

I Agree

I confirm that I do NOT have any TWO OR MORE or the following symptoms of COVID-19: fever, new or worsening cough, sore throat, runny nose or headache *

I Agree

I confirm that I have not tested positive for COVID-19. *

I Agree

I confirm that I am not waiting for the results of a test for COVID-19. *

I Agree

I confirm that this is not currently a period where I required to self-isolate for 14 days. *

I Agree

Signature of patient: *

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

I Agree

Date: *

COVID-19 Safety Protocal – Pre-Appointment Screening

COVID-19 DENTAL RISK ACKNOWLEDGEMENT FORM:

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