COVID-19 Pre-Screening Assessment

COVID-19 Pre-Screening Assessment

For Red Deer Dental Hygiene Studio Inc
ALL VISITOR MUST SANITIZE AND WEAR A MASK UPON ENTRY.

Do you wish to continue? If yes, continue. If no, please processed to the bottom of this form for response.
1) Have you traveled out of Canada in the last 14 days?*

YesNo
If Yes, please indicate details of Where and When:
Date

MonthDayYear
Date

2) Have you had any ONE of the following symptoms?*

	Yes	No
NEW Cough
NEW Shortness of breath of difficulty breathing
NEW Sore Throat

OR and TWO of the following symptoms:*

	Yes	No
Runny Nose
Nausea / Vomiting / Diarrhea
NEW Fatigue or Malaise
Generalized Muscle Aches and/or pain
NEW Headache
NEW Loss of Taste and/or Smell
Chills / Sweats / Shaking
Fever ( usually 100.0 degree or higher)

3) In the last 14 days have you?:*

	Yes	No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with anyone with flu-like symptoms?

4) OFFICE USE ONLY (Temperature will be taken and recorded by upon arrival with a contactless thermometer. What was their temperature at the time of arrival?
If answered “Yes” to any one question or had a fever >38 please use the following response:

We apologize but since there was a "Yes" response in this Pre-Screening Assessment and or fever >38 we are not allow permitted to preform dental treatment on you today and it is recommended that you self isolate.

For the safety of others and yourself we recommend you contact your health care provider immediatly.

Thank you for your understanding and cooperation in helping us keep echother safe.
5) Have you tested positive of COVID-19?*

YesNo
If Yes, please enter date of when diagnosed:

MonthDayYear
Date
I certify to the best of my knowledge; this information is accurate.
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Date*

MonthDayYear
DateHourMinutesAM/PM Option
Refused to participate:

We apologize but it is our responsibility to keep everyone in our clinic safe as possible. We hope you can understand our position and desire to participate at a later time.
Should be Empty: