Blue Quill Dental Centre COVID-19 Screening Form COVID-19 Pandemic Dental Treatment Screening Form CMOH Order 05-2020 legally obligates any person who has the following cough, fever, shortness of breath, runny nose, or sore throat (that is not related to a pre-existing illness or health condition) to be in isolation (quarantine) for 10 days from the start of symptoms, or until symptoms resolve, whichever takes longer. If they are exhibiting any of these symptoms, it is suggested they complete the COVID-19 Self-Assessment online tool to determine if they should be tested.Please confirm the following:Name* First Last Email* Home Phone* I understand the novel coronavirus causes the disease known as COVID-19. 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. 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. I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Alberta Health Services: Fever > 38 Degrees Celsius New cough or worsening chronic cough Sore throat or painful swallowing New or worsening shortness of breath Difficulty Breathing Flu-like symptoms Runny Nose * 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. I fall into other high risk categories and my dentist and I have discussed the risks, and I have agreed to proceed with treatment. I confirm that to my knowledge I am not currently positive for the novel coronavirus. Please note: Any individual who has gone in for testing on their own volition as an asymptomatic individual does not need to indicate that. I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus that was ordered due to contact tracing or because I had identified risk factors. Please note: Any individual who has gone in for testing on their own volition as an asymptomatic individual does not need to indicate that. I understand that Alberta Health Services has asked individuals to maintain physical distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive dental treatment. 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 Alberta Health, the Communicable Disease Control or any other governmental health agency. I have received one dose of a COVID-19 vaccine. I have received two doses of a COVID-19 vaccine. I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatment at Blue Quill Dental Centre completed during the COVID- 19 pandemic. I verify that I am not currently required to be in isolation due to international travel measures. PhoneThis field is for validation purposes and should be left unchanged. Δ
