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Patient Acknowledgement & Screening Online Form

    Patient Acknowledgement: COVID-19 Pandemic Emergency Dental Risk

    Please read the patient acknowledgement below, and initial or sign in all areas indicated.

    I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand that the novel
    coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.


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


    I understand that oral surgery/dental procedures can create water and/or blood spray, which is one way that the novel coronavirus can
    spread. I understand that 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 an elevated risk of contracting the novel coronavirus simply by being in the dental office.


    I confirm that I do NOT have any TWO OR MORE or the following symptoms of COVID-19: (i) fever, (ii) new or worsening cough, (iii) sore
    throat, (iv) runny nose or (v) headache.


    If I received COVID-19 test results in the past three (3) months, the last results I received were negative. If applicable, approximate
    date of test:


    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 self-isolate for 14 days.


    Upon arriving at the office, you will be asked to:

    • Wear a mask. In the event that you do not have your own we will provide you with one.
    • Sanitize your hands with provided sanitizer.
    • Possibly have your temperature taken with a no-contact infrared thermometer.
    • Confirm the patient screening questions.

    Please be advised that only patients with an appointment will be permitted to enter the office. To promote social distancing, please also
    do not arrive too early or too late for your scheduled appointment by either waiting in your vehicle and calling the office when you
    arrive.

    I verify the information I have provided on this form is truthful and complete. I knowingly and willingly consent to have emergency
    surgical/dental treatment completed during the COVID-19 pandemic.

    Completed by:



    Adapted from Dental Association of PEI COVID-19 Pandemic Emergency Dental Risk Acknowledge by Patient.

    Patient Screening Form



    PatientOther (specify)


    PhoneEmailOther (specify)

    SCREENING QUESTIONS

    In the last 14 days, have you travelled outside of Canada?

    If exempt from federal quarantine requirements as directed by the border agent at your point of entry (for example, you have two or more doses of a COVID-19 vaccine and have met the specific conditions, or an essential worker who crosses the Canada-US border regularly for work), select "No"

    Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?

    In the last 5 days have you experienced any of these symptoms?

    Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.

    Select "None of the above" if all of these apply:

    • you have completed your isolation period of 5 days or you tested negative for COVID‐19 on one PCR test or rapid molecular test or two
      rapid antigen tests taken 24 to 48 hours apart, and
    • you do not have a fever, and
    • your symptoms have been improving for 24 hours (48 hours if you have nausea, vomiting, and/or diarrhea)

    • Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher

    • Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)

    • Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)

    • Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have

    • Unusual, long-lasting (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, a sudden injury, fibromyalgia, or other known causes or conditions you already have)

    • Unusual, fatigue, lack of energy (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)

    • Painful or difficulty swallowing (not related to post-nasal drip, acid reflux, or other known causes or conditions you already have)

    • Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have

    • New, unusual, long-lasting (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, tension-type headaches, chronic migraines, or other known causes or conditions you already have)

    • Not related to irritable bowel syndrome, anxiety, menstrual cramps, medication side effects, or other known causes or conditions you already have

    Are you 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?


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