COVID19

Covid-19 Pre-Screen & Patient Acknowledgement Form

Pre-Screen Information

Name:

Email:

Phone:

Date of Birth:

Appointment Date:

New or Existing Patient:
New PatientExisting Patient

Covid Vaccination Status
Current status of vaccination against Covid-19?
0 Doses1 Dose2 Doses3 Doses

Brand of Vaccine (if multiple, please write each brand):

Date of Last Covid-19 Vaccine Dose:

Do you have a fever or have felt hot or feverish anytime in the last two weeks?
NOYES

Do you have any of these symptoms: Dry cough, shortness of breath, difficulty breathing, sore throat, runny nose or any nasal congestion, difficulty swallowing, decrease or loss of sense of smell or taste, chills, headaches, unexplained fatigue or muscle aches, nausea, vomiting, diarrhea, abdominal pain, pink eye?
NOYES

Have you had a confirmed case of COVID-19?
NOYES

Have you been in contact with anyone that has been confirmed COVID-19 positive, or persons self-isolating because of a determined risk for COVID-19, or with anyone with acute respiratory illness?
NOYES

Have you returned from travel outside of Canada in the last 14 days?
NOYES

Have you been in close contact with anyone that has travelled outside of Ontario in the past 14 days?
NOYES

Are you over the age of 70 that have experienced any of the following symptoms: delirium, unexplained or increased number of falls, worsening of chronic conditions, or acute functional decline?
NOYES

Covid-19 Patient Acknowledgement

I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand 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, it is recommended to stay home and avoid close contact with other people when at all possible.
I understand and accept:
YESNO

I understand our government have asked individuals to maintain social distancing of at least 6 feet and I recognize it is not possible to maintain this distance while receiving dental treatment.
I understand and accept:
YESNO

I understand there is an elevated risk of contraction of the novel coronavirus due to other patients, the characteristics of the virus and dental procedures.
I understand and accept:
YESNO

I confirm that I am not waiting for the results of a test for COVID-19 and that I have not been tested positive for COVID-19 in the past.
I confirm this statement:
YESNO

If I received COVID-19 test results in the past 3 months, the last results I received were negative.
This statement is true:
YESNOI was not tested

Approximate date of Covid-19 test if applicable:

I confirm that this is not currently a period where I am required to self-isolate for 14 days.
I confirm this statement:
YESNO

Information Update

Any new medications or medical conditions/issues?
YESNO

List of new medications and/or any new medical conditions/issues?

Insurance, phone number or address changes?

Would you like a different type of reminder/notification:
TextEmailVoice Call

I verify the information I have provided on this Patient Acknowledgement Form is truthful and accurate. I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.
YES

Your Signature:
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