Patient Screening Form

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Patient Consent and Screening Form

Account ID *

Practice Name *

Practice Recipient Email *

Patient Consent Form

I understand the novel coronavirus causes the disease known as COVID-19. Symptoms may include (but are not limited to): fever, cough, sore throat, shortness of breath, difficulty breathing, flu-like symptoms, runny nose, loss of taste/smell, chills, fatigue, rash.

I have considered whether I am in a high-risk category, including (but not limited to): diabetes, cardiovascular disease, hypertension, lung diseases including moderate to severe asthma, being immunocompromised, active cancer, over age 65.

I understand that due to the characteristics of the COVID-19 and the limitations on physical distancing when out in public and during dental procedures, that there is a risk of contracting COVID-19, especially where local prevalence rates are high.

I understand that the dental practice is following all infection prevention and control guidelines in order to minimize the risk to patients, the dental team, and the community.

I understand that there may be modifications to appointment scheduling, available treatment options, and office protocols during the pandemic to help eliminate the spread of the virus.

Acknowledgement and Consent *

I Acknowledge That

I have received information about COVID-19 including its symptoms and risk factors.

I have informed the dental practice if I have ANY symptoms or risk factors.

I understand the risk of transmission in a dental office can be minimized by infection prevention and control measures but it cannot be completely eliminated.

I know it is my right to ask questions about COVID-19 and have them answered to my satisfaction.

I consent to and wish to proceed with the procedures.

Signature *

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Patient Screening Form

1. Have you tested positive for COVID-19 in the past 6 weeks or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE in the past 14 days? *

Yes No

2. Do you or have you recently had (14-21 days) any of the following symptoms: *

Yes

No

Fever or feeling hot, chills/feverish

Shortness of breath or other difficulties breathing

Cough or worsening of a chronic cough

Flu-like symptoms such as stomach upset, diarrhea, headache, or fatigue

Recent alteration or loss of taste or smell

Any new, unusual symptoms, e.g., malaise or sudden onset of runny nose

3. Have you been in contact with anyone with confirmed COVID-19 or with any of the above symptoms of possible COVID-19? *

Yes No

4. Do you have heart, lung or kidney disease, diabetes, or any auto-immune disorders? *

Yes No

5. Have you travelled in the past 14 days outside of the province and/or the country? *

Yes No

6. Have you been exposed to COVID-19 in a work or public setting? *

Yes No

“YES” responses to any of these questions would indicate the need for a deeper discussion with the dentist before proceeding with treatment. Whenever possible, patients with one or more risk factors should be rescheduled to a later date.

By signing this document, I acknowledge the importance of protecting the health of my dental provider and other patients. I confirm that all answers I have given above are true to the best of my knowledge.

Patient Name *

First Name Last Name

Date *

Date

Date of Birth *

Phone Number *

Area Code Phone Number

Signature *

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Please verify that you are human *