Patient Screening Form

Patient Name *

Patient Age *

Parents or Legal Guardians Name if Patient is a Minor:

1. Have you (or the patient, if a minor) tested positive for COVID-19 in the past 10 days or are you waiting for results from COVID-19 testing? *

Yes

No

2. Have you (or the patient, if a minor) been in contact with any person who has been diagnosed with COVID-19 in the last 10 Days? *

Yes

No

3. Have you (or the patient, if a minor) been advised by your physician or provincial health authority to quarantine due to a possible exposure to COVID-19 in the last 10 days? *

Yes

No

4. Do you (or the patient, if a minor) have any of these symptoms currently or in the last 10 days: Fever? Cough? Difficulty breathing? Sore throat? Swollen Lymph nodes?Painful swallowing? Runny nose? *

Yes

No

5. Have you (or the patient, if a minor) experienced a recent loss of smell or taste in the last 10 days? *

Yes

No

6. If you have recently travelled outside of Canada, did you follow current government regulations regarding testing and quarantine? *

Yes

No

N/A

7. Do you (or the patient, if a minor) have heart, lung or kidney disease, diabetes, or any auto-immune disorders? *

Yes

No

*

By clicking here and printing my name below, I confirm that I know COVID‐19 virus is a serious and highly contagious disease. The World Health Organization has classified it as a pandemic. You could contract COVID‐19 from a variety of sources. Our Clinic is taking every precaution to limit the risk of transmission between patients, staff and our dentists. Despite these efforts you understand that there is still a risk of contracting COVID-19 within the dental clinic. Specifically, dental procedures can create water spray (called aerosols) which is a possible source of transmission of the virus. As a result, our Clinic is taking extra precautions such as limiting aerosol generating procedures, modified sanitation techniques and the use of personal protective equipment. I acknowledge that my Dentist has informed me about COVID-19 and the risk of transmission during my visit to the Dental Clinic. My Dentist has also adequately explained to me the risks with delaying my dental treatment as such I wish to proceed with the proposed treatment. I confirm that I have read this Waiver and understand and accept that there is a risk of contracting the COVID‐19 virus in the dental office or with dental treatment in general. I have read and understand the information stated above

Patient / Please Type the First & Last Name of Person Completing This Form *

Spam Blocker

COVID-19 Patient Screening

Looking for a Dentist in Surrey, BC?