Patient Screening Form Name* First Last Age*Email* Phone*Have you travelled outside of Canada in the past 14 days?* Yes No Do you have any of the following symptoms? Fever New onset of cough Worsening chronic cough Shortness of breath Difficulty breathing Difficulty swallowing Decrease or loss of sense of taste or smell Chills Headaches Unexplained fatigue/malaise/muscle aches (myalgias) Nausea/vomiting, diarrhea, abdominal pain Pink eye (conjunctivitis) Runny nose/nasal congestion without other known cause I have none of these symptoms 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 PATIENT ACKNOWLEDGEMENT: COVID-19 PANDEMIC DENTAL RISK Please read the patient acknowledgement below, and initial or sign in all areas indicated. Agreements* 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. 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. 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. 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. I agree to complete a COVID-19 screening questionnaire as required by the Ministry of Health. If I received COVID-19 test results in the past three (3) months, the last results I received were negative. I confirm that I am not waiting for the results of a test for COVID-19. I confirm that this is not currently a period during which public health authorities required I self-isolate for 14 days. Signature of Patient, Parent or Guardian*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.
