COVID-19 Pre-screening Form
Phone Number - preferably a cell number
These questions must be answered honestly under penalty of law. If you answered YES to any of the questions 1 through 4 then please submit this form and call our office (902 835-1031). An answer of YES does not automatically exclude you from treatment. Please answer YES or NO to each of the following questions. Please note: If there will be an attendant (maximum 1 person) with the patient these answers will apply to both of you.
1) In the past 48 hours have you had or experienced; a fever (above 38 degrees) OR cough (new or worsening)
2) Do you have any two of these symptoms (new or worsening): Sore throat (difficulty swallowing), runny nose/nasal congestion, shortness of breath or headache?
3) Have you been in close personal contact, without PPE, with a suspected or confirmed COVID-19 patient within the past 2 weeks?
4) Have you traveled outside of Nova Scotia (by air, car, bus or otherwise) in the past 2 weeks?
5) Are you over the age of 60?
6) Do you have any of the following medical conditions which would put you in a high-risk category: diabetes, cardiovascular disease, hypertension, lung diseases including moderate to severe asthma, being immuno-compromised and/or have an active malignancy?
7) I have reviewed the latest
COVID-19 potential risk sites
Explain any YES answers in the box below:
Signature: By writing your name in the box below, you accept that due to the characteristics of the novel coronavirus, and the nature of dental procedures, you could have an elevated risk of contracting COVID-19. I understand, to help minimize the risk to patients and staff. Hammond Dental Centre is following the Return to Practice Guidelines set forth by the Provincial Dental Board and the Chief Medical Officer of Nova Scotia.
Signature can be written with your mouse or your finger.
Please advise the office (902 835-1031) if any of these answers change before your appointment time.
Should be Empty: