Screening Questionnaire
To ensure the safety of all our patients and staff, please complete the following questions prior to your appointment. We will not be able to see you for your scheduled appointment if we do not have the completed questionnaire. Thank you!
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Email *
Who is completing this questionnaire (ie. patient or other[specify])? *
Patients first and last name. *
Phone Number *
Did the patient have close contact with anyone with acute respiratory illness or travelled outside of Canada in the past 14 days? *
Does the patient have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19 without wearing PPE? *
Does the patient have any of the following symptoms? *
Does the patient have any of the following conditions that increase vulnerability to COVID-19? *
If the patient is 70 years of age or older, are they experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?
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If there have been any changes to the patient's health history since the last dental appointment, please list here:
If you become aware that patient becomes COVID-19 positive or develops COVID-19 symptoms within 14 days after today’s visit, please notify us ASAP as the clinic needs to report the exposure. *
Treatment Consent: Please be assured that our office has always met or exceeded the requirements set forth for sterilization and infection control by the RCDSO and PHO, and will continue to do so. However, it is more likely to contract COVID-19 infection (or any other communicable disease) in any public space, including a dental office. Our office will provide for socially distant appointment scheduling, and also has added a number of new technologies and techniques to the practice to enhance our level of safety. However, due to the nature of the dental procedures, social distance is not possible between the patient and clinical staff/doctor. 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 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. 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. Clicking "I understand" below indicates that the risks involved are accepted, and that consent is given for treatment to be provided by the office of Brock Starr Dental Care and staff. *
Thank you for completing the screening questions. Your health and safety is our top priority! One of our staff will be asking you to sanitize your hands and we will be taking your temperature with a touchless forehead thermometer.
All patients entering the office must wear a mask - please bring your own. As part of our safety protocols and strict social distancing measures, parents and siblings will not permitted inside the office.* Thank you for your cooperation!
*Exception: A parent of new patient, very young patient, or special needs patient
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