COVid Consent Patient Screening  Form

Identify yourself and explain the purpose of the call, which is to determine whether there are any special considerations for their dental appointment. Have the patient answer the following questions.

Screening Questions

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

YES
NO

2. Do you have any of these symptoms: New or worsening cough? New or worsening shortness of breath? Difficulty breathing? Sore throat or painful swallowing? Runny nose?

Yes
NO

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

Yes
No

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

Yes
No

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

Yes
No

6. Have you returned from travel within Canada from a location known affected with COVID-19 in the last 14 days?

Yes
No

7. Is your workplace considered high risk?

Yes
No

Patient Vulnerability

8. Are you over the age of 65?

Yes
No

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

Yes
No

LOCATION

10470 Mayfield Rd NW, Mayfield Square

Edmonton Alberta

Canada, T5P 4P4

PHONE: 780-484-8573

HOURS:

Sunday Closed

Monday 08:00 AM - 06:00 PM

Tuesday - Wednesday 08:00 AM - 08:00 PM

Thursday 08:00 AM - 06:00 PM

Friday - Saturday 08:00 AM - 04:00 PM

Closed on all holidays

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