COVID-19 Screening Questionnaire and Consent Form COVID-19 Screening Questionnaire and Consent Please take a moment to fill out our online COVID-19 Screening Questionnaire and Consent form within 24 hours of your visit. This is mandatory prior to you receiving treatment. All information is kept completely confidential. If this form is completed more than 24 hours before your visit, you will be asked to complete it again. First Name(Required)Middle NameLast Name(Required)Consent and Risk Acceptance 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 dental procedures create water spray which is one way that the novel coronavirus can spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus. 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 understand that Cypress Dental has taken all reasonable steps to decrease and minimize my risk of exposure to the COVID-19 virus. In spite of these steps taken, I understands that there is no way to fully eliminate the risk of viral transmission. I further understand that the nature of dental treatment means that physical distancing is not possible when being treated. I understand that staying home and/or utilizing Telehealth (virtual or phone consultations) is still the safest option for reducing the risk of COVID-19 transmission. Confirmation(Required) I agree and understand completely the statement above and I am requesting treatment with the knowledge of the associated risks of COVID-19 Please check the box of your chosen answer. ALL questions must be answered. ** If you answer YES to any of the questions, please provide us more detail in the space to the right of your answer. Are you currently presenting with any of the following symptoms:Fever or ChillsFever or Chills(Required) yes no if yes, please provide details here(Required)Cough, shortness of breath, or difficulty breathing Cough, shortness of breath, or difficulty breathing(Required) yes no if yes, please provide details here(Required)Flu-like symptoms Flu-like symptoms(Required) yes no if yes, please provide details here(Required)Headaches or unexplained fatigue/malaise Headaches or unexplained fatigue/malaise(Required) yes no if yes, please provide details here(Required)Sore throat or difficulty swallowing Sore throat or difficulty swallowing(Required) yes no if yes, please provide details here(Required)Loss of smell or taste Loss of smell or taste(Required) yes no if yes, please provide details here(Required)Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19 or anyone with acute respiratory illness in the last 14 days? confirmed case of COVID-19(Required) yes no if yes, please provide details here(Required)Are you waiting for the results of a laboratory test for the coronavirus?waiting for the results of a laboratory test(Required) yes no if yes, please provide details here(Required)Have you travelled outside of Canada or British Columbia or had close contact with anyone who has travelled outside of Canada or British Columbia in the last 14 days? Have you travelled outside of Canada(Required) yes no if yes, please provide details here(Required)Office Policy for COVID-19 The following guidelines and recommendations are implemented for the safety of our patients and staff. We kindly ask if you could bring your own personal mask and to wear it upon entering the dental office. We appreciate if you could attend the appointment unaccompanied unless the patient is a minor requiring a parent/guardian, or if the patient needs assistance (please inform the clinic ahead of time). Please adhere to all safety guidelines as directed or requested by staff members while inside the dental office (this include following social & physical distancing measure, and washing or sanitizing hands prior to and after treatment). If you are currently sick with any symptoms please notify the dental office immediately. We will reschedule your appointment to a later date when you are feeling better. Patients will notify the dental office and/or staff if there are any changes in their answer for the COVID-19 screening questionnaire and/or any changes in current medical condition. Confirmation(Required) I confirm and understand the above policy and agree to follow the safety guidelines and recommendations above. By signing, I agree to Cypress Dental’s policy for COVID-19 Date:(Required) YYYY dash MM dash DD Draw Your Signature(Required)
