Covid-19 Screening - Towngate Dentall

Date / Time *

Patient Full Name *

Please read the patient acknowledgement below, and initial or sign in all areas indicated.

Pre-Screen

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: Fever, New Onset Cough, Worsening Chronic Cough, Shortness Of Breath, Sore Throat, Difficulty Swallowing, Decrease Or Loss Of Sense Of Taste Or Smell, Chills, Headaches, Unexplained Fatigue - Malaise - Muscle Aches, Nausea, Vomiting, Diarrhea, Abdominal Pain, Pink Eye, Running Nose, Nasal Congestion Without Other Known Cause?

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

Patient Acknowledgement

Any "Yes" responses must be discussed with the managing dentist prior to your appointment.

I, (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. *

Patient Signature *

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