Prescreening Form

*Date:

*Patient Name:

*Patient Age:

*Who is completing this form?: PatientOther

If Other:

Cell Phone:

Home Phone:

*E-mail:

PLEASE SELECT YES OR NO IN ANSWER TO EACH OF THE FOLLOWING QUESTIONS

*Have you travelled outside 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?

• *Fever greater than 38°C? YesNo
• *New oneset of cough? YesNo
• *Worsening chronic cough? YesNo
• *Shortness of breath? YesNo
• *Difficulty breathing? YesNo
• *Sore throat? YesNo
• *Difficulty swallowing? YesNo
• *Decrease or loss of sense of taste or smell? YesNo
• *Chills? YesNo
• *Headaches? YesNo
• *Unexplained fatigue/malaise/muscle aches (myalgias)? YesNo
• *Nausea/vomiting, diarrhea, abdominal pain? YesNo
• *Pink eye (conjunctivitis)? YesNo
• *Runny nose/nasal congestion without other known cause? YesNo

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? ANSWER NO IF YOU ARE UNDER 70 YEARS OF AGE* YesNo

PATIENT ACKNOWLEDGEMENT: COVID-19 PANDEMIC EMERGENCY DENTAL RISK

PLEASE READ THE PATIENT ACKNOWLEDGEMENT BELOW, AND CHECK EACH BOX AND SIGN AS INDICATED. By checking each box below, you acknowledge that you are understanding and agreeing to each statement. ALL FIELDS REQUIRED

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.

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.

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.

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.

I agree to complete a COVID-19 screening questionnaire as required by the Ministry of Health.

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

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

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

By signing below, 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.

SIGNATURE OF PATIENT, PARENT OR GUARDIAN