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. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

Acknowledge


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I understand that dental procedures create water spray which is one way that the novel coronavirus can spread. 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 visits by other dental patients, the characteristics of the novel coronavirus, and that of dental procedures, that I have an elevated risk of contracting the novel coronavirus simply by being in a dental office.

Acknowledge


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I understand that Public Health has asked individuals to maintain social distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive dental treatment.

Acknowledge


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I understand that Public Health has asked individuals to maintain social distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive dental treatment.

Acknowledge


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

Acknowledge


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Did the person receive their final (or second) vaccination dose more than 14 days ago?

Yes, patient is fully vaccinated

No


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Does the person have any of the following symptoms:
. Fever and/or chills
. New onset of cough or worsening chronic cough
. Shortness of breath
. Decrease or loss of sense of taste or smell

Yes

No


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If an adult > 18 years of age: Is the person experiencing unexplained fatigue / lethargy / malaise / muscle aches (myalgias)

Yes

No


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If child < 18 years of age: Is the person experiencing nausea/vomiting, diarrhea

Yes

No


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Has the person tested positive for COVID-19 in the past 10 days or have they been told they should be isolating?

Yes

No


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Did the person travel outside of Canada in the past 14 days?

Yes

No


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Has the person had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

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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