Covid Screening Forms

COVID-19 Patient Screening Form
Patient First Name:*
Patient Last Name:*
Who answered

PatientOther
Preferred contact Method

PhoneEmailOther
Do you have a fever of have felt hot or feverish in the last two weeks?

YesNo
Do you have any of these symptoms; Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? Sneezing? Post-nasal drip?

YesNo
Have you experienced a recent loss of taste or smell?

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

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

YesNo
Is your workplace high risk?

YesNo
Occupation
Are you over the age of 70?

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

YesNo
Please read the patient acknowledgment below, initial or sign in 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 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. blank
I understand the federal and provincial government have asked individuals to maintain social distancing of a least 2 meters (6ft) and I recognize it is not possible to maintain this distance while receiving dental treatment.
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I understand that it is possible that oral surgery/dental procedures can create water and/or blood spray, which may be one way that the novel Coronavirus can spread. The ultra-fine nature of the spray can linger in the air for minutes to sometime hours, which can transmit the novel Coronavirus.
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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.
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I confirm that I do NOT have any TWO OR MORE of the following symptoms of COVID-19: fever, new or worsening cough, sore throat, runny nose or headache.
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I confirm that I have not tested positive to for COVID-19.
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I confirm that I am not waiting for the results of a test for COVID-19.
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I confirm that this is not currently a period where I require to self-isolate for 14 days.
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I verify the information I have provided on this form is truthful and accurate. I knowable and willingly consent to have dental treatment completed during COVID-19 pandemic.
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Signature of patient:

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Date:

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COVID-19 Patient Screening Form

Please read the patient acknowledgment below, initial or sign in all the areas indicated.