PATIENT ACKNOWLEDGEMENT: COVID-19 PANDEMIC DENTAL RISK Please read the patient acknowledgement below, and initial or sign in all areas indicatedI 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 Day Year 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 GUARDIANDATE PATIENT SCREENING FORMName: 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 answer NO please complete Q4 and QSQ2. Do you have any of the following symptoms?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 QS ONLY IF YOU ARE NOT FULLY VACCINATEDQ4. 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 CommentsThis field is for validation purposes and should be left unchanged.
