Stonehaven Dentistry | Mississauga Dentist

COVID-19 Pre-Screening Form

Due to the COVID-19 Pandemic we have instituted an additional dental treatment consent form. Please submit the form prior to arrival.

Patient's Name:

E-mail:

Have you received your final (or second) vaccination dose more than 14 days ago?
Yes No

*A fully immunized individual is defined as any individual >14 days after receiving their second dose of a two-dose COVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series (i.e. Johnson and Johnson).

I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Public Health Services:

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Fever > 38°C
Cough (New or Worsening)
Shortness of Breath
Difficulty Breathing
Sore Throat
Difficulty Swallowing
Decrease or loss of sense of taste or smell
Chills

Headaches
Unexplained fatigue / Malaise / Muscule Aches (myalgias)
Pink eye (conjunctivitis)
Runny nose / nasal congestion without other known cause
Nausea/vomiting, diarrhea, abdominal cramps (of unknown origin)

I confirm that I am not in a high risk category, including: diabetes, cardiovascular disease, hypertension, lung diseases including moderate to severe asthma, being immunocompromised, having active malignancy, or over age 65.

I fall into the following high risk category and my dentist and I have discussed the risks, and I agree to proceed with treatment.

I confirm that nobody in my household currently has a runny nose, cough or any of the common symptoms noted above.

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I confirm that I am not currently positive for the novel coronavirus.

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I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus.

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I verify that I have not returned to Ontario from any country outside of Canada whether by car, air, bus or train in the past 14 days.

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I understand that any travel from any country outside of Canada, including travel by car, air, bus or train, significantly increases my risk of contracting and transmitting the novel coronavirus. Canadian and Ontario Health Services require self-isolation for 14 days from the date a person has returned to Canada.

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I understand that Public Health has asked individuals to maintain social distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive dental treatment.

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I verify that I have not been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by Public Health, the Communicable Disease Control or any other governmental health agency.

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List of Dental Treatment:

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above listed dental treatment completed during the COVID-19 pandemic.

Signature:

Printed Name: