Covid Screening Form Patient Name Patient Age Email Phone Number Who Answered Patient Other (specify) Contact Method Phone Email Other Identify yourself and explain the purpose of the call, which is to determine whether there are any special considerations for their dental appointment. Have the patient answer the following questions. Have you had close contact with anyone with acute respiratory Illness or travelled outside of Ontario in the past 14 days? Pre-Screen Yes No Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19? Pre-Screen Yes No Do you have any of the following symptoms: Fever New onset of cough Worsening chronic cough Shortness of breath Difficulty breathing Sore throat Difficulty swallowing Decrease or loss of sense of taste or smell Chills Headaches Unexplained fatigue/malaise/muscle aches (myalgias) Nausea/vomiting, diarrhea, abdominal painPink eye (conjunctivitis) Runny nose/nasal congestion without other known cause Pre-Screen Yes No Are you 70 years of age or older, experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions? Pre-Screen Yes No *Any “yes” response must be discussed with the managing dentist immediately. Patient Acknowledgement: I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand that the novel coronavirus virus 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. Initial I understand the federal and provincial authorities have asked individuals to maintain social distancing of a least two (2) meters (six (6) feet) and I recognize it is not possible to maintain this distance while receiving dental treatment. Initial I 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. Initial I 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. Initial I confirm that I do NOT have any TWO OR MORE or the following symptoms of COVID-19: (i) fever, (ii) new or worsening cough, (iii) sore throat, (iv) runny nose or (v) headache. Initial If I received COVID-19 test results in the past three (3) months, the last results I received were negative. If applicable, approximate date of test: Date I confirm that I am not waiting for the results of a test for COVID-19. Initial I confirm that this is not currently a period during which public health authorities required I self-isolate for 14 days. 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 Name Date Submit
