Patient Screening Form

General Information

Patient Screening

Have you/they recently been tested for COVID-19?
Have you/they tested positive for COVID-19?
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
Are you/they having shortness of breath or other difficulties breathing?
Do you have a cough?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Have you/they experienced recent loss of taste or smell?
Are you/they in contact with any confirmed COVID-19 positive patients?
Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.
Is your/their age over 60?
Do you/they have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?
Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

I,

, knowingly and willingly consent to have dental treatments including dental hygiene treatments completed during the COVID-19 pandemic. I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing. Dental procedures create water spray which is how disease is spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the COVID-19 virus. We do use the Extraoral Suction unit with triple layer of HEPA medical grade filters and UV light to sterilize the air during treatment to significantly minimize aerosols up to 95%. However, we cannot eliminate 100% of expressed aerosols.

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We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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