Patient Screening Form

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Name *

First

Last

Age *

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? *

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 of COVID-19? *

Yes
No

Have you returned from travel outside of Canada in the last 14 days?

Yes
No

Have you returned from travel within Canada from a location known affected with COVID-19? *

Yes
No

Are you over the age of 60? *

Yes
No

Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder? *

Yes
No

Which do you have? (Heart Disease, Lung disease, Kidney Disease, Diabetes, Auto-Immune Disorder)

Is your workplace Considered High Risk? *

Yes
No

Where do you work?

Patient Acknowledgement: COVID-19 Pandemic Emergency Dental Risk

Please read the patient acknowledgement below, and initial all the 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. *

Accept

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

Accept

I understand that oral surgery/dental procedures can create water and/or blood pray, which is 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. *

Accept

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. *

Accept

I confirm that I DO NOT HAVE ANY of the following Symptoms of COVID-19: Fever, New or Worsening Cough, Sore Throat, Runny Nose or headache. *

Accept

I confirm that I have not tested positive for COVID-19 / I confirm that I am not waiting for the results of a test for COVID-19 *

Accept

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

Accept

Signature

Date

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