Covid Prescreening

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

YesNo

Have you tested positive to COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

YesNo

Do you have any of the following symptoms?

FeverNew onset of coughWorsening chronic coughShortness of breathDifficulty breathingSore throatDifficulty swallowingDecrease or loss of sense of taste or smellChillsHeadachesUnexplained fatigue/malaise/muscle aches (myalgias)Nausea/vomiting, diarrhea, abdominal painPink eyeRunny nose/nasal congestion without other known cause

If you are 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?

YesNo

I, the undersigned, understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand that the novel coronavirus 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, the undersigned, understand the 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, the undersigned, 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, the undersigned, 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, the undersigned, agree to complete a CIVD-19 screening questionnaire as required by the Ministry of Health.

If I, the undersigned, received COVID-19 tests results in the past three (3) months, the last results I received were negative.

I, the undersigned, confirm that I am not waiting for the results of a test for COVID-19.

I, the undersigned, confirm that this is not currently a period during which public health authorities required I self-isolate for 14 days.

I, the undersigned, 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 COVD-19 pandemic.