Covid-Screening-Forms

642 Upper James Street, Hamilton, Ontario. L9C 2Z2

Phone: +1-905-574-9617 Fax: +1-905-574-9691

Email: info@thedentalplace.co Website: www.thedentalplace.co

Patient Screening Form

Use this form to screen patients before their appointment and when they arrive for their appointment.

Patient Name: *

Patient age: *

Who answered: *

Patient Other (specify)

Contact: Please enter a phone number or email *

Have you had close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days? *

Yes No

Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19? *

Yes No

Do you have any of the following symptoms - Fever, New onset of cough, Worsening chronic cough, Shortness of breath, Difficulty breathing, Sore throat, Difficulty swallowing, Decrease or loss of sense of taste or smell, Chills, Headaches, Unexplained fatigue/malaise/muscle aches (myalgias), Nausea/vomiting, diarrhea, abdominal pain, Pink eye (conjunctivitis), Runny nose/nasal congestion without other known cause *

Yes No

Are you 70 years of age or older, experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions? *

Yes No

Any "yes" response must be discussed with the managing dentist immediately.

Tell the patient when they arrive at the office, they will be asked to:

Sanitize their hands
Answer the questions again
Possibly have their temperature taken
Complete a form acknowledging the risk of COVID-19

Advise the patient:

Only patients are allowed to come to the office
If possible, to wait in their car until their appointment, call the office when they arrive

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

I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand that the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. For this reason, I understand that the federal and provincial authorities have recommended that Ontarians stay home and avoid close contact with other people when at all possible.

I understand the federal and provincial authorities have asked individuals to maintain social distancing of a least two (2) meters (six (6) feet) and I recognize it is not possible to maintain this distance while (initial) receiving dental treatment.

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 confirm that I do NOT have any TWO OR MORE or the following symptoms of COVID-19: (i) fever, (ii) new or worsening cough, (iii) sore throat, (iv) runny nose or (v) headache.

If I received COVID-19 test results in the past three (3) months, the last results I received were negative. If applicable, approximate date of test:

I confirm that I am not waiting for the results of a test for COVID-19.

I confirm that this is not currently a period during which public health authorities required I self-isolate for 14 days.

I verify the information I have provided on this form is truthful and complete. I knowingly and willingly consent to have emergency surgical/dental treatment completed during the COVID-19 pandemic.

Initials *

SIGNATURE OF PATIENT *

Clear

Date *

Date

Patient Acknowledgement: COVID-19 Pandemic Emergency Dental Risk