1) Riverwood Dental Wellness Pre-screening Form
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Email *
Name (First Name, Last Name) *
Phone *
1. Do you or have you had a cough in the last 14-21 days? *
2. Do you have a fever or have you felt hot or feverish recently (14-21 days)? *
3. Are you having shortness of breath or other difficulties breathing? *
4. Do you or have you had muscle aches in the last 14-21 days? *
5. Have you experienced recent loss of taste or smell? *
6. Do you or have you had any other flu-like symptoms in the last 14-21 days? (check all that apply) *
Required
7. Are you in contact with any suspected or confirmed COVID-19 positive patients? *
8. Have you travelled out of country or to any regions with high rates of COVID-19 disease activity in the past 14 days ? *
9.  Do you have any of the following?
10.  Are you over the age of 70?
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By initialing below, you are effectively providing your signature, indicating that all the information on this form is truthful and accurate, to the best of your knowledge and should you develop any of the above mentioned symptoms prior to your appointment, please notify us immediately.(Please type your initials below) *
Covid-19 Dental Treatment Acknowledgement Form
I understand there is currently a health pandemic associated with COVID-19 and the novel coronavirus.  (Please initial below) *
I understand public health authorities have recommended maintaining social distancing of at least 2 metres (6 feet) and is not possible to maintain this distance while receiving dental treatment. (Please initial below) *
I understand that oral surgery/dental procedures can create water spray and that there may be an elevated risk of contracting and spreading the novel coronavirus in a dental office.  (Please initial below) *
I confirm that I have not tested positive for COVID-19 and that I am not currently waiting for the results of a test for COVID-19. *
I hereby consent to have dental treatment completed during this COVID-19 pandemic. (Please initial below) *
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Riverwood Dental.