Please complete our COVID-19 pre-screening form

Patient First & Last Name



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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.

Acknowledge


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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 dental treatment.

Acknowledge


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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.

Acknowledge


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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.

Acknowledge


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I agree to complete a COVID-19 screening questionnaire as required by the Ministry of Health.

Yes

No


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If I received COVID-19 test results in the past three (3) months, the last results I received were negative OR I received a letter from Public Health clearing me.

Yes

No


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

Acknowledge


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

Acknowledge


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Have you travelled outside of Canada in the past 14 days?

Yes

No


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Have you tested positive to COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

Yes

No


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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
. Chills
. Headaches

Yes

No


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Are you experiencing any of the following:
. Decrease or loss of sense of taste or smell
. Unexplained fatigue/malaise/muscle aches (myalgias)
. Nausea/vomiting, diarrhea, abdominal pain
. Pink eye (conjunctivitis)
. Runny nose/nasal congestion without other known cause

Yes

No


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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?

Yes

No


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I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatments completed during the COVID-19 pandemic.

Acknowledge


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Confirm your email address:

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