PATIENT SCREENING FORM

Upon arrival

For patients safety and to manage physical distancing, our front door remains locked. When you arrive, please call us at 613 521 3939 to let us know that you’ve arrived for your appointment, someone will come and meet you at the door.

Mask Mandatory

Your safety is our priority and thank you in advance for your cooperation. If you have any questions, please do not hesitate to contact us.

Call 613-521-3939 or email info@shifadentistry.com

Please be advised that when you arrive for your appointment, we will take your temperature and ask quick screening questions. Please call us when you arrive for your appointment. Your safety is our first priority.

Patient Name *

Patient age

Phone *

Email *

Preferred Contact Method

Have you travelled outside of Canada in the past 14 days?

Have you tested positive to COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

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 pain

Pink eye (conjunctivitis)

Runny nose/nasal congestion without other known cause

Do you have any of the following symptoms:

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?

PATIENT ACKNOWLEDGEMENT: COVID-19 PANDEMIC EMERGENCY DENTAL RISK

Please read the patient acknowledgement below, and initial or sign in all areas indicated.

I understand the novel corona virus causes the disease known as COVID-19 and that it is currently a pandemic. | 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, | 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 | 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. | 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 | have an elevated risk of contracting the novel coronavirus simply by being in the dental office.

( Initial )

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

( Initial )

If I received COVID19 test results in the past 3 months, the last results I received were negative:

( Initial )

If applicable, approximate date of test://

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 heaith authorities required | self-isolate for 14 days.

( Initial )

I verify the information | have provided on this form is truthful and complete. | knowingly and willingly consent to have emergency surgical/dental treatment completed during the COVID-19 pandemic.

SIGNATURE OF PATIENT, PARENT, or GUARDIAN

Date//