Patient Acknowledgement - Dental Risk Screening
All patients to fill in this form ON THE DAY of your appointment.
REMINDER: Please wait in your vehicle and call us when you arrive. All patients are required to wear a mask and sanitize their hands upon entering the office.
Today's Date: [REMINDER this is to be filled in on the day of your appointment NOT before] *
Full name of Patient: *
Please READ and agree to the patient acknowledgement below
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 Ontarian's stay home and avoid close contact with other people when at all possible. *
I understand that that federal and provincial authorities have asked individuals to maintain social distancing of at least two (2) meters (six (6) feet) and I recognize it is not possible to maintain this distance while receiving dental treatment. *
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. *
I agree to complete a Covid-19 screening questionnaire as required by the Ministry of Health. *
*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. (Initial) *
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. *
Screening Questions
Have you had close contact with anyone with an acute respiratory illness or traveled outside of Canada in the past 14 days? *
Do you have a confirmed case of Covid-19 or had close contact with a confirmed case of Covid-19? *
Do you have any of the following symptoms:
Are you 70 years of age or older and experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions? *
If yes, what are you experiencing?
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