COVID Patient Screening & Consent

Patient Name *

First Name Last Name

Do you have a fever (> 37.5°C) or have you felt feverish anytime in the last 2 weeks? *

Yes No

Do you have any of the following? *

Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? Sneezing? Post nasal drip? NONE OF THE ABOVE

Have you experienced recent loss of taste or smell? *

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 returned from travel within Canada from a location known affected with COVID-19 in the last 14 days? *

Yes No

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

Yes No

Do you have any of the following? *

Heart disease Lung disease Kidney disease Diabetes Any auto-immune disorders NONE OF THE ABOVE

Please provide details:

Are you over the age of 70? *

Yes No

Is your workplace considered high risk for COVID exposure? (e.g. front line worker) *

Yes No

Are you currently positive for the novel coronavirus? *

Yes No

Are you awaiting laboratory test results for the novel coronavirus? *

Yes No

Positive response to any of the above would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

Dental Treatment Consent. Please Check: *

I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. I understand that dental procedures create water spray 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. I understand that due to the frequency of visits of other dental patients, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have an elevated risk of contracting the novel coronavirus simply by being in a dental office. I understand that BC’s Provincial Health Officer has asked individuals to maintain social distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive dental treatment.

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatment completed.

Name of parent / guardian signee (if applicable)

Signature *

Clear

Date

Patient Screening & Dental Treatment Consent