COVID-19 Questionnaire & Consent

Patient Information

First name:

Last name:

Date of birth:

Phone number:

Email address:

Risk of infection

At [INSERT PRACTICE NAME], we follow all requirements for Infection Control and Prevention, including all enhanced directives issued. We are taking all necessary precautions to prevent transmission of COVID-19, along with any and all other infection causing viruses or bacteria. Certain dental procedures create a water spray which is one way that the novel coronavirus can spread. Despite these efforts, given the unique attributes of the novel coronavirus, there may be an elevated risk of infection.

To help facilitate your appointment, please answer all fields below.

Have you tested positive for COVID-19?

Yes No

Are you waiting for the results of a laboratory test for COVID-19?

Yes No

If yes, please provide recovery date:

Have you had contact with a person who has tested positive for COVID-19?

Yes No

If yes, please explain:

Have you had contact with a person who is exhibiting symptoms of COVID-19?

Yes No

If yes, please explain:

Have you travelled to any regions affected by COVID-19 in the last 14 days?

Yes No

If yes, please explain:

Do any of the following medical conditions apply to you?

Heart disease

Lung disease

Kidney disease

Diabetes

Any auto-immune disorders

None of the above

Please select if your occupation is any of the following:

First responder

Healthcare worker

Employee at a child/adult care facility

Attendee at a child/adult care facility

None of the above

If you are 60 years of age and older, are you experiencing any of the following symptoms:

Delirium

Unexplained or increased number of falls

Acute functional decline

Worsening of chronic conditions

None of the above

Consent

I hereby consent to dental treatment despite any possible elevated risks associated with such treatment during this time of the COVID-19 pandemic, which risks have been explained to me.

Patient/parent/guardian name:

Date of submission

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