Please fill out and submit the form below prior to your visit (you must also complete the Patient Acknowledgement Form as well)

PATIENT SCREENING FORM

Use this form to screen patients before their appointment and when they arrive for their appointment.

Staff screener

Patient Name

Patient age

Who answered

Patient

Other (specify)

Contact Method

Phone

Other

Identify yourself and explain the purpose of the call, which is to determine whether there are any special considerations for their dental appointment. Have the patient answer the following questions.

Screening Questions	Pre-Screen	In-Office
Have you travelled outside of Canada in the past 14 days?	Yes No	Yes No
Have you tested positive to COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?	Yes No	Yes No
Do you 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	Yes No	Yes No
If you are 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?	Yes No	Yes No

Any “yes” response must be discussed with the managing dentist immediately.

Tell the patient when they arrive at the office, they will be asked to:

Sanitize their hands.
Answer the questions again.
Have their temperature taken.
Complete a form acknowledging the risk of COVID-19.

Advise the patient:

Only patients are allowed to come to the office.
If possible, to wait in their car until their appointment, call the office when they arrive

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