COVID - 19 Screening Form
This form must be filled out by all patients prior to visiting our clinic.
Name
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First Name
Last Name
Date
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Month
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Day
Year
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Symptoms of COVID-19 include:
A fever >38 degrees Celsius
Cough
Sore throat
Shortness of breath
Difficulty breathing
Flu-like symptoms
Runny nose
Do you have any of the above symptoms of COVID-19? (If you have any of the above we will ask that you reschedule)
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Yes
No
Are you, or is anyone in your household, awaiting results for a COVID-19 test?
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Yes
No
Are you, or anyone in your household, currently in isolation for testing positive for COVID-19?
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Yes
No
Have you EVER tested positive for COVID-19?
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Yes
No
Have you experienced the recent loss of taste or smell?
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Yes
No
Even if you do not have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?
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Yes
No
In the last 14 days, have you been in physical contact with any person that is currently COVID-19 positive?
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Yes
No
Do you have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?
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Yes
No
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I knowingly and willingly consent to have an emergency or standard dental treatment completed during COVID -19 pandemic
I understand the novel coronavirus causes the disease known as COVID-19 and that it has a long incubation period during which carriers of the virus may not show symptoms and still be contagious
I confirm that I am not currently positive for the novel coronavirus
I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus
I verify that I have not returned from any country outside of Canada in the past 14 days
I understand that Public Health has asked individuals to maintain social distancing of at least 2 meters (6ft) ,and it is not possible to maintain this distance and receive dental treatment
I verify that I have not been identified as a contact of someone who has tested positive for COVID-19 or been asked to self-isolate by Public Health
Signature
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date Picker Icon
Submit
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