Patient Wellness Screening and Acknowlegement Form

Must be submitted within 24 hours prior to your appointment

Please correct the errors described below.

This form must be completed by everyone who will be entering our offices.

Has the patient travelled outside of Canada in the past 14 days?

Does the patient have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19 without wearning the appropriate PPE?

Does the patient have any of the following symptoms?

  • Fever
  • New onset of cough
  • Worsening chronic cough
  • Shortness of breath
  • Difficulty breathing
  • Sore throat
  • Difficulty swallowing
  • Decrease or loss of sense of taste or smell
  • Chills
  • Headaches
  • Unexplained fatigue/malaise/muscle aches (myalgias)
  • Nausea/vomiting, diarrhea, abdominal pain
  • Pink eye (conjunctivitis)
  • Runny nose/nasal congestion without other known cause

Is the patient 70 years of age or older, experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?

Patient Pandemic Informed Consent

Our office follows all requirements for Infection Control and Prevention, including all enhanced directives issued by the Public Health Agency of Canada and the Ontario Ministry of Health. Our clinic and all treatment areas are sterilized frequently, including after each dental procedure and patient visit. We take all the necessary precautions to prevent transmission of the COVID-19 virus along with any and all other infection causing viruses or bacteria.

For each paragraph below please check to indicate that you have read and understand it

I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. For this reason, I understand that the federal and provincial authorities have recommended that Ontarians stay home and avoid close contact with other people when at all possible.

I understand the federal and provincial governments have asked individuals to maintain physical distancing of at least two (2) metres (six (6) feet) and I recognize it is not possible to maintain this distance while receiving dental treatment.

I understand that dental procedures can cause water and/or blood spray, which is one important 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 visits of other patients, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have, or the patient has, an elevated risk of contracting the novel coronavirus simply by being in a dental office.

If I, or the patient, received COVID-19 test results in the past three (3) months, the last results I, or the patient, received were:

I confirm that I am not waiting for the results of a test for COVID-19

I confirm that this is not currently a period during which public health authorities required I, or the patient, self-isolate(s) for 14 days.

Acknowledgement and Consent:

By signing this consent form, I verify the information I have provided on the Patient Pre-Screening Questionnaire and the Patient Pandemic Consent form is truthful and complete. I knowingly and willingly consent to have Orthodontics on Danforth provide orthodontic treatment for myself or for my child, named above, despite the elevated risks associated with treatment during this time of COVID-19 pandemic.

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