emergency dentist - London Ontario Dentist

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Patient Name:
Patient Age:
Are you a:
PatientCaregiver / Legal Guardian / Parent

1.

Do you or have you ever had a confirmed case of COVID-19?

Pre-Screen

YesNo

2.

Have you been tested for COVID - 19 what were the results?
(If you never tested for Covid, then write N/A)

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PositiveNegetiveNever Tested

3.

Have you had close contact with a confirmed case of COVID-19 without PPE?

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YesNo

4.

Have you traveled outside of Ontario in the past 14 days?

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YesNo

5.

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

Pre-Screen

YesNo

6.

Are you 70 years of age or older, experiencing any of the following
symptoms: delirium, unexplained or increased number of falls,
acute functional decline, or worsening of chronic conditions?

Pre-Screen

YesNo

COVID-19 Pandemic Dental Risk

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. Initials

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. Initials

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. Initials

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. Initials

I confirm that I do NOT have any TWO OR MORE of the following symptoms of COVID-19:
(i)fever, (ii) new or worsening cough, (iii) sore throat, (iv) runny nose or (v) headache. Initials

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

I confirm that this is not currently a period during which public health authorities required I self-isolate
for 14 days. Initials

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.

Full Name*
Date (MM-DD-YYYY)*

Your Signature*

Please Click Twice to submit the form.

Patient Screening Form COVID-19

Please Fill All The Details

1.

Pre-Screen

2.

Pre-Screen

3.

Pre-Screen

4.

Pre-Screen

5.

Pre-Screen

6.

Pre-Screen

COVID-19 Pandemic Dental Risk

Please read the patient acknowledgement below, and initial or sign in all areas indicated

About Our Clinic

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