Leave this field blank PATIENT ACKNOWLEDGEMENT:COVID-19 PANDEMIC DENTAL RISK Please read the patient acknowledgement below, and initial or sign in all areas indicated I understand the SARS CoV-2 virus causes the disease known as COVID-19 and that it is currently a pandemic. I understand that the SARS CoV-2 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 exercise caution when leaving home, and otherwise avoid close contact with other people when possible. (initial) I understand the federal and provincial authorities have asked individuals to maintain social distancing of at least two (2) meters (six (6) feet) and I recognize it is not possible to maintain this distance while receiving dental treatment. (initial) I understand that due to the visits of the other patients, the characteristics of the SARS CoV-2 virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the novel coronavirus simply by being in the dental office. (initial) I agree to complete a COVID-19 screening questionnaire as required by the Ministry of Health. (initial) If I received COVID-19 test results in the past three (3) months, the last result I received were negative OR I received a letter from Public Health clearing me. (initial) If applicable, approximate date of test: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 I confirm that I am not waiting for the results of a test for COVID-19. (initial) I confirm that this is not currently a period during which public health authorities required I self-isolate. (initial) I verify the information I have provided on this form is truthful and complete. I knowingly and willingly consent to have dental treatment completed during the COVID- 19 pandemic. SIGNATURE OF PATIENT, PARENT OR GUARDIAN Start drawing Clear Done Start over DATE Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 PATIENT SCREENING FORM Name: Email Address: Age: Phone: SCREENING QUESTIONS ———Q1. Did you receive your final (or second) vaccination dose , more than 14 days ago? Yes No **If you answered NO, please complete Q4 and Q5. ———Q2. Do you have any of the following symptoms? Yes No Fever and/or chills Yes No New onset of cough or worsening chronic cough Yes No Shortness of breath Yes No Decrease or loss of sense of taste or smell Yes No If adult >18 years of age: unexplained fatigue/lethargy /maIaise/muscle aches (myalgias) Yes No If child <18 years of age: nausea/vomiting, diarrhea Yes No ———Q3. Have you tested positive for COVID-19 in the past 10 days or have been told to isolate? Yes No PLEASE COMPLETE Q4 AND Q5 ONLY IF YOU ARE NOT FULLY VACCINATED ———Q4. Did you travel outside of Canada in the past 14 days? Yes No ———Q5. Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? Yes No Send
