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Covid-19 Screening
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Covid-19 Screening
Date / Time
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Patient Full Name
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Please read the patient acknowledgement below, and initial or sign in all areas indicated.
Pre-Screen
Have you had close contact with anyone with acute respiratory illness or traveled outside of Canada in the past 14 Days?
Yes
No
Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?
Yes
No
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?
Yes
No
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?
Yes
No
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.
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Patient Signature
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Name
Submit