Covid-19 Screening & Consent Form | Westside Dental Centre

COVID-19

Patient Screening Form
Patient Name*
First Last
Date of birth*
YYYY dash MM dash DD
Are you fully vaccinated for Covid-19?*
An individual is considered fully vaccinated if it has been more than 2 weeks since they received the last shot of a 2-dose vaccine (for example, Moderna or Pfizer) or a single dose vaccine (J&J).
- Yes
- No
Do you have a fever or have felt hot or feverish anytime in the last two weeks?*
- Yes
- No
Do you have any of the following symptoms:
- Dry cough
- Shortness of breath
- Difficulty breathing
- Sore throat
- Runny nose
- Cough that’s new or worsening
- Difficulty swallowing
- Stuffy or congested nose
- Pink eye
- Digestive issues
- Muscle aches
- Extreme tiredness that is unusual
- Headache that is unusual or long lasting headache
- For young children and infants: sluggishness or lack of appetite
- Falling down often
Have you experienced a recent loss of smell or taste?*
- Yes
- No
Have you been in contact with any confirmed COVID-19 positive patients, or person self-isolating because of a determined risk for COVID-19?*
- Yes
- No
Have you returned from travel outside of Canada in the last 14 days?*
- Yes
- No
Are you over the age of 60?*
- Yes
- No
Do you have any of the following conditions?
- Heart disease
- Lung disease
- Kidney disease
- Diabetes
- Auto-immune disorder
- Pregnant
Consent*
I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand the novel coronavirus has a long incubation period during which carries of the virus may not show symptoms and still be contagious. For this reason, it is recommended to stay home and avoid close contact with other people when at all possible.*
Consent*
I understand the oral surgery/dental procedures can create water and/or blood spray, which is one important way that the novel coronavirus can spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus.*
Consent*
I understand the federal and provincial governments have asked individuals to maintain social distancing of at least 2 meters (6 feet) and I recognize it is not possible to maintain this distance while receiving dental treatment.*
Consent*
I understand that due to the visits of other patients, the characteristics of the novel coronavirus, and the characteristics of the dental procedures, that I have an elevated risk of contracting AND SPREADING the novel coronavirus simply by being in the dental office.*
Consent*
I confirm that I have NOT tested POSITIVE for COVID-19.*
Consent*
I confirm that I am not waiting for the results of a test for COVID-19.*
Consent*
I confirm that this is not currently a period where I required to self-isolate for 14 days.*
Consent*
I confirm that I do NOT have any TWO or MORE of the following symptoms of COVID-19: fever, new or worsening cough, sore throat runny nose or headache.*
Consent*
I verify that the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.*
Patient Signature*
Name
This field is for validation purposes and should be left unchanged.

COVID-19

Patient Screening Form