Please fill out "Patient Name, "Patient Age" and Answer the Pre-Screen questions: Check for YES


Screening Questions:
YesNo
1-Do you have a fever or have felt hot or feverish anytime in the last two weeks?
YesNo
2-Do you have any of these symptoms: Dry cough? Shortness of breath?Difficulty breathing? Sore throat? Runny nose? Sneezing? Post-nasal drip?
YesNo
3-Have you experienced a recent loss of smell or taste?
YesNo
4-Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?
YesNo
5-Have you returned from travel outside of Canada in the last 14 days?
YesNo
6-Have you returned from travel within Canada from a location known affected with COVID-19?
YesNo
7-Is your workplace considered high risk?


Screening Questions:
YesNo
8-Are you over the age of 70?
YesNo
9-Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?

• Any “yes” response for questions 1-7 must be discussed with the managing dentist immediately.

Please read the patient acknowledgement below.

I understand there is currently a health pandemic associated with COVID-19 and the novel coronavirus.

I understand public health authorities have recommended maintaining social distancing of a least 2 meters (6 feet) and I recognize it is not possible to maintain this distance while receiving dental treatment.

I understand that oral surgery/dental procedures can create water and/or blood spray, and that there may be an elevated risk of contracting and spreading the novel coronavirus in a dental office.

I confirm that I do NOT have any two or more or the following symptoms of COVID19: fever, new or worsening cough, sore throat, runny nose or headache, and that this is not currently a period where I am required to self-isolate for 14 days.

I confirm that I have not tested positive for COVID-19 and that I am not currently waiting for the results of a test for COVID-19.

I hereby consent to have dental treatment completed during the COVID-19 pandemic.

Signature of Patient: