Jasper Place Orthodontics

Patient's Name and Guardian Name (if entering office) *

Date *

Have you tested positive for COVID-19 in the past 14 days? Or have you been tested for COVID-19 and not received your results yet? *

Yes
No

Do you have a fever or have felt hot or feverish anytime in the last 10 days? *

Yes
No

Do you have any of the following symptoms: new cough or worsening cough? New shortness of breath or worsening shortness of breath? Difficulty breathing? Sore throat or painful swallowing? Flu-like symptoms? Runny nose? *

Yes
No

Have you experienced a recent loss of smell or taste? *

Yes
No

Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19? Note: Healthcare workers who have worn appropriate PPE may answer No. *

Yes
No

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

Yes
No

Is your workplace considered high risk? (e.g. routine close contact with many people) Note: Healthcare workers who have worn appropriate PPE may answer No. *

Yes
No

I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. I understand that due to the frequency of visits of other dental 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 a dental office. (Please Initial Below) *

I confirm I know that there are categories of people who are considered to be high risk. I understand the high risk category factors are being 65 years of age or older, heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder. (Please Initial Below) *

(If Applicable) I fall into the following high risk categories:

My Dentist and I have discussed the risks and I have agreed to proceed with treatment. (Please Initial Below) Note: Only Applicable if you filled out the "High Risk Categories" section above.

Pre-Screening Questionnaire