Patient Screening Form

All patients are to be screened before their appointment AND when they arrive for their appointment.

Staff Screener (Please Leave Blank for Clinic Staff to Complete)

Patient Name:*

Patient Age*

Who Answered:*
PatientOther

A dental team member will contact you and identify themselves and will then explain the purpose of the call before your appointment. The reason for this will be to determine whether there are any special considerations for your dental appointment. Please answer the following questions.

Contact Method :*
PhoneEmailOther

Screening Questions

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

Before Appointment*
YesNo

In Clinic (Please Leave Blank for Clinic Staff to Complete)
YesNo

Patient temperature at appointment. If elevated, provide mask to patient.

Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose?

Before Appointment*
YesNo

In Clinic (Please Leave Blank for Clinic Staff to Complete)
YesNo

Have you experienced a recent loss of smell or taste?

Before Appointment*
YesNo

In Clinic (Please Leave Blank for Clinic Staff to Complete)
YesNo

Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?

Before Appointment*
YesNo

In Clinic (Please Leave Blank for Clinic Staff to Complete)
YesNo

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

Before Appointment*
YesNo

In Clinic (Please Leave Blank for Clinic Staff to Complete)
YesNo

Have you returned from travel within Canada from a location known affected with COVID-19?

Before Appointment*
YesNo

In Clinic (Please Leave Blank for Clinic Staff to Complete)
YesNo

Are you over the age of 60 and have any underlying health conditions?

Before Appointment*
YesNo

In Clinic (Please Leave Blank for Clinic Staff to Complete)
YesNo

Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?

Before Appointment*
YesNo

In Clinic (Please Leave Blank for Clinic Staff to Complete)
YesNo