Patient Covid pre-Screening Form

Patient Covid pre-Screening Form

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Patient Name:(Required)
Have you travelled outside of the country in the past 14 days? (Whether you have an exemption through border control or not or if you are considered an essential worker)
Are you, or have you in the last 14 days,been in contact with any confirmed COVID-19 positive patients?
Have you tested positive for COVID-19 in the past 3 months?
Do you have a confirmed case of COVID-19 or waiting on test results?
If fully immunized, have you had contact with a confirmed case of COVID-19 ?
If not fully immunized, have you had contact with a confirmed case of COVID-19 without wearing appropriate PPE?
Have you been told you should be isolating?
Have you been exposed to anyone who has travelled outside the country in the past 2 weeks and has returned? ( for instance, someone who is quarantining in your home?)
Do you have any of the below listed symptoms:

List of 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
  • If adult >18 years of age: unexplained fatigue, lethargy malaise muscle aches (myalgias)
  • If child <18 years of age: nausea/vomiting, diarrhea

Office protocol to follow:

1. You MUST wear a mask in all public areas while in the office. This includes hallways, as well as the waiting room. Your nose and mouth must be fully covered. You may take your mask off when you enter the Operatory and are seated. If you need a new mask after your procedure, we can provide one for you but you must put your mask back on after exiting the Operatory.

2. You MUST call when you arrive, BEFORE entering the office and we will tell you when to enter. We recommend calling from your car if possible.

3. Do not come earlier than asked to since we cannot let you into the waiting room until it is clear. Appointments are scheduled at specific times for a reason.

4. If we are running late or are taking a bit longer, it is for your health and safety that you not enter the office at your appointment time if we are not ready. This means we are disinfecting the room and using our filtration machine to mitigate any aerosols from the patient prior. We do this in between each patient and will not bring you in unless we are ready.

5. Please come alone as we cannot accommodate more than a specific number or patients in the waiting room. If you need to come with your child or if you are accompanying someone who needs assistance, please let us know ahead of time.

6. We do have a ramp for wheelchair or walker access on the left side of our building, past the driveway. If you can, please let us know if you will be using this entrance as we greet everyone through our alternate entrance at the front of the building.

I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand the novel coronavirus virus has a long incubation period during which the carriers of the virus may not show symptoms and still be contagious. For this reason it is recommended to stay home and avoid close contact with other people when at all possible.
I understand that oral surgery/dental procedures can create water and/or blood spray, which is one important 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.
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 AND SPREADING the novel coronavirus simply by being in the dental office.
I confirm that I have not tested positive for COVID-19.
I understand the federal and provincial governments have asked individuals to maintain a social distance of at least 2 metres (6 feet) and I recognize it is not possible to maintain this distance while receiving dental treatment.
I confirm that this is not currently a period where I am required to self-isolate for 14 days.
I confirm that I am not waiting for the result of a test for COVID-19.

Once fully read and reviewed, please make sure that the above document is filled out appropriately. By signing below and submitting this document, we are assuming that it has been read in its entirety. All patient signatures will be verified for authenticity in the office.

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