Step 1 of 2 50% Patient Screening Form (Please fill online and send to the office on the day of your appointment)Patient Name:Patient Email Address: Patient Age:Please answer the following Screening Questions:1) Have you travelled outside of Canada in the past 14 days?YesNo2) Have you tested positive to COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?YesNo3) Do you have any of the following symptoms?Fever:YesNoNew onset of cough or Worsening Chronic cough:YesNoShortness of breath:YesNoDifficulty breathing:YesNoSore throat:YesNoDifficulty swallowing:YesNoDecrease or loss of sense of taste or smell:YesNoChills:YesNoHeadaches:YesNoUnexplained fatigue/malaise/muscle aches:YesNoNausea, vomiting, diarrhea, abdominal pain:YesNoPink eye (conjunctivitis):YesNoRunny nose/nasal congestion without other known cause:YesNo4) If you are 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?YesNoIf “yes” to any of the above questions, please call our office before you come to your appointment. Non-emergency appointments will be rescheduled. Remember when you arrive at the office, you will need to wear a mask, sanitize your hands, and have your temperature taken. Do not forget to complete our COVID-19 Risk Acknowledgement form next. Thank you. Patient Acknowledgement: Covid-19 Pandemic Dental Risk 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 my 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.(initial)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 receiving dentaI treatment.(initial)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.(initial)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.(initial)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.(initial)If I received COVID-19 test results in the past three (3) months, the last results I received were negative.(initial)If appiicable, approximate date of test: Date Format: MM slash DD slash YYYY 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 for 14 days.(initial)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.Signature of patientDate Date Format: MM slash DD slash YYYY
