Skip to content
HOME
SERVICES
MAKE APPOINTMENT
COVID-19 PATIENT INTAKE
admin
2020-10-27T13:49:33+00:00
Covid-19 Intake & Release
Step
1
of
3
33%
Please read the patient acknowledgement below, and initial or sign in all areas indicated.
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.
*
(initial)
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.
*
(initial)
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.
*
(initial)
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.
*
(initial)
I agree to complete a COVID-19 screening questionnaire as required by the Ministry of Health.
*
(initial)
If I received COVID-19 test results in the past three (3) months, the last results I received were negative.
*
(initial)
If applicable, approximate date of test.
MM slash DD slash YYYY
I confirm that I am not waiting for the results of a test for COVID-19.
*
(initial)
I confirm that this is not currently a period during which public health authorities required I self-isolate for 14 days.
*
(initial)
I verify the information I have provided on this form is truthful and complete. I knowingly and willingly consent to have emergency dental treatment completed during the COVID-19 pandemic.
SIGNATURE OF PATIENT, PARENT, or GUARDIAN
*
Date
*
MM slash DD slash YYYY
PATIENT SCREENING FORM
Use this form to screen patients before their appointment and when they arrive for their appointment.
Patient Name
*
First
Last
Patient D.O.B
*
MM slash DD slash YYYY
Who Answered Call?
*
Patient
Other
Please Specify
*
Contact Method
*
Phone
Email
Other
Email
*
Phone
*
Other
*
Have you travelled outside of Canada in the past 14 days?
*
Yes
No
Have you tested positive to COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
*
Yes
No
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 • 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
*
Yes
No
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
*For Office Use Only Below*
Date
Temperature
Signature
Go to Top
