Banaag Dental Clinic Triage Form

Patient Acknowledgement: COVID-19 Dental Risk

This form is a requirement before your appointment. Please answer this form honestly.
Name*

First NameLast Name
Sex

MaleFemale
Have you received the COVID-19 vacination?*

I have received the first doseI have received the second doseI have received the third doseI have received the Fourth DoseI have not been vaccinated
Age*
Contact Number*
Body Temperature (in Celsius)
ONLY FOR UNDERAGE PATIENTS:
1. In the past 14 days, have you or any member of your household, traveled outside of Ontario?

YesNo
2. In the past 14 days, have you or any member of your household had any contact with any COVID-19 patient?*

YesNo
1. Are you waiting for a COVID-19 test result?*

YesNo
4. Are you currently in period during which public health authorities require you self-isolate for 14 days?*

YesNo

2. Do you have any of the following symptoms:*

3. Have you had a COVID-19 test in the past month?

YesNo
3a. IF YES: What was the date of last test?

MonthDayYear
IF NO: Skip question
3b. What was the result of the test?
IF NO: Skip question
INFORMED CONSENT:

I understand that oral surgery/dental procedures can create water and/or blood spray, which is one way that the novel coronavirus can spread. I understand that 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 visits of other 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 the dental office.
I have read the above three paragraphs, and I consent:*

YesNo
For the good of the entire community, I am TRUTHFULLY answering the questionnaire and fully understand the informed consent:*

Clear
Signature of Patient/Guardian
Date*

MonthDayYear
Should be Empty:

Patient Acknowledgement: COVID-19 Dental Risk