PATIENT SCREENING AND ACKNOWLEDGMENT

PATIENT SCREENING

QUESTIONS

DO YOU HAVE ANY OF THE FOLLOWING SYMPTOMS?

HAVE YOU TESTED POSITIVE FOR COVID-19 IN THE PAST 10 DAYS OR HAVE YOU BEEN TOLD TO ISOLATE? IF YES, PLEASE WAIT UNTIL YOUR SYMPTOMS ARE CLEAR BEFORE BOOKING AN APPOINTMENT(required)

HAS ANYONE IN YOUR HOUSEHOLD TESTED POSITIVE FOR COVID-19 IN THE PAST 10 DAYS OR IS IN ISOLATION?(required)

HAVE YOU HAD CLOSE CONTACT WITH A CONFIRMED CASE OF COVID-19 WITHOUT WEARING APPROPRIATE PPE?(required)

HAVE YOU TRAVELLED OUTSIDE OF ONTARIO IN THE PAST 10 DAYS?(required)

HAVE YOU BEEN VACCINATED? (required)

PATIENT ACKNOWLEDGMENT

COVID-19 PANDEMIC EMERGENCY DENTAL RISK

PLEASE READ THE PATIENT ACKNOWLEDGEMENT BELOW, AND INITIAL OR SIGN IN ALL AREAS NOTES

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