Staff screener:*

Patient Name:

Patient Age:

Who answered?:

Patient ( )

Other (specify) :

Contact Method:

Phone

Email

Other

1. I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Alberta Health Services:*

Fever > 38℃ anytime in the last 10 days

Cough

Sore Throat /Painful Swallowing

Shortness of Breath

Difficulty Breathing

Flu-Like Symptoms

Runny Nose

None of the above

2. Have you experienced a recent loss of smell or taste?

YES

NO

3. Have you been in contact with any confirmed COVID-19 positive patient(s), or a person self-isolating because of a determined risk for COVID-19? (Healthcare workers who have worn PPE may answer NO)

YES

NO

5.Are you over the age of 65?

YES

NO

6.Do you have any of the following?

Heart disease

Lung disease

Kidney disease

Diabetes

Any auto-immune disorder

None of the above

DD / MM / YYYY

COVID-19 Pandemic Dental Treatment Consent Form