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

Are you currently positive, awaiting test results, or required to self-isolate because of a determined risk for COVID-19? *

Yes No

Do you have any of the following symptoms? *

Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? Sneezing? Loss of taste or small? Loss of appetite? 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 outside of Canada, or 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 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 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 understand that dental procedures create water spray, and that there may be an elevated risk of contracting the novel coronavirus in a dental office.

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