Patient Screening Form

Patient Name*

First Last

Q1: Did you receive your final (or second) vaccination dose more than 14 days ago?*

Yes
No

Screening Questions

Q2: Do you have any of the following symptoms:*

Fever and/or chills
New onset of cough or worsening chronic cough
Shortness of breath
Decrease or loss of sense of taste or smell
If adult >18 years of age: unexplained fatigue/lethargy/malaise/muscle aches (myalgias)
If child <18 years of age: nausea/vomiting/diarrhea
None

Q3: Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating?*

Yes
No

Q4: Have you travelled outside of Canada in the past 14 days?

Yes
No

Q5: Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

Yes
No

Consent*

I verify that the information I have provided in this form is truthful and complete. I knowingly and willingly consent to have emergency surgical dental treatment completed during the COVID-19 pandemic.

Signature*

Phone

This field is for validation purposes and should be left unchanged.