COVID-19 SCREENING FORM ~ PLEASE CONFIRM ALL POINTS AND COMPLETE WITH FULL SIGNATURE
If you have recently traveled anywhere, have any signs of cold or flu-like symptoms, or have been in contact with someone exhibiting symptoms, please self-isolate and do not visit the dental office for 14 days for precautionary reasons.
Patient Name * Date *
Date Format: MM slash DD slash YYYY I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious * I understand that dental procedures create water spray which is one way that the novel coronavirus can spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus. * I understand that due to the frequency of visits of other dental patients, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have an elevated risk of contracting the novel coronavirus simply by being in a dental office. * I confirm that I am not presenting any of the following symptoms of COVID-19: *
Fever > 37.5 C
Shortness of breath
Flu-like symptoms I confirm that I am not currently positive for the novel coronavirus * I verify that I have not returned to British Columbia from any country outside of Canada in the past 14 days. * I understand that any travel from any country outside of Canada significantly increases my risk of contracting and transmitting the novel coronavirus. BC’s Provincial Health Officer requires self-isolation for 14 days from the date a person has returned to Canada. * I understand that BC’s Provincial Health Officer has asked individuals to maintain social distancing of at least 2 meters and it is not possible to maintain this distance and receive dental treatment. * I verify that I have not been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by BC’s Provincial Health Officer, the Communicable Disease Control or any other governmental health agency. * I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic. * Signature of Patient * Name
This field is for validation purposes and should be left unchanged.