Covid-19 Pre-Screening

COVID-19 PRESCREENING FORM

Please read the patient acknowledgement below, and check mark/fill in all areas indicated prior to your appointment with Toth Dental Hygiene (Julia Toth, RDH).

* Indicates required field

Name *

First

Last

Date *

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, it is recommended to and avoid close contact with other people when at all possible.

Please take and record your temperature: *

Please check the box to confirm the above: *

Check here

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

I understand that due to the visits of other patients, going to other patients households, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have an elevated risk of contracting and spreading the novel coronavirus.

Please check the box to confirm all of the above: *

Check here

I confirm that I do NOT have any TWO OR MORE or the following symptoms of COVID-19: fever, new or worsening cough, sore throat, runny nose or headache.
I confirm that I have not tested positive for COVID-19.
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 where I required to self-isolate for 14 days.

Please check the box to confirm all of the above: *

Check here

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental hygiene treatment completed during the COVID-19 pandemic. Please fill out your full name again and include your email (for confirmation purposes and to send a copy to you if you require):

Name *

First

Last

Email *

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