Patient Screening Form - Havenview Dental

All patients are to be screened before their appointment AND when they arrive for their appointment.

Staff Screener (Please Leave Blank For Clinic Staff to Complete)

Patient Name:*

Patient Age*

Who Answered:*

Patient
Other

Other’s Full Name*

Relationship to Patient*

A dental team member will contact you and identify themselves and will then explain the purpose of the call before your appointment. The reason for this will be to determine whether there are any special considerations for your dental appointment. Please answer the following questions.

Contact Method :*

Phone
Email
Other

Phone Number*

Email Id*

Specify*

Screening Questions

Do you have a fever or have felt hot or feverish anytime in the last two weeks?

Before Appointment*

Yes
No

In Clinic (Please Leave Blank for Clinic Staff to Complete)

Yes
No

Please Provide Details*

Patient temperature at appointment. If elevated, provide mask to patient.

Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose?

Before Appointment*

Yes
No

In Clinic (Please Leave Blank for Clinic Staff to Complete)

Yes
No

Specify*

Have you experienced a recent loss of smell or taste?

Before Appointment*

Yes
No

In Clinic (Please Leave Blank for Clinic Staff to Complete)

Yes
No

Please Provide Details*

Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?

Before Appointment*

Yes
No

In Clinic (Please Leave Blank for Clinic Staff to Complete)

Yes
No

Please Provide Details*

Have you returned from travel outside of Canada in the last 14 days?

Before Appointment*

Yes
No

In Clinic (Please Leave Blank for Clinic Staff to Complete)

Yes
No

Please Provide Details*

Have you returned from travel within Canada from a location known affected with COVID-19?

Before Appointment*

Yes
No

In Clinic (Please Leave Blank for Clinic Staff to Complete)

Yes
No

Please Provide Details*

Are you over the age of 60 and have any underlying health conditions?

Before Appointment*

Yes
No

In Clinic (Please Leave Blank for Clinic Staff to Complete)

Yes
No

Please Provide Details*

Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?

Before Appointment*

Yes
No

In Clinic (Please Leave Blank for Clinic Staff to Complete)

Yes
No

Please Provide Details*

Patient Signature

Date Signed*

Date of Appointment*

Any "Yes" response must be discussed with the managing dentist immediately.

When you arrive at the office, you will be asked to:

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

Please be advised:

Only patients are allowed to come to the office.
If possible, please wait in your car until your appointment, and call the office when you arrive to let us know you are waiting nearby.