Phone(613) 707-6768Location208 Bridge St E, Belleville, ON

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COVID-19 Patient Screening Form

Please complete the following form or download the form and bring it into your appointment.

Please review all questions all of the pre-screening questions. If you answer yes to any of the questions below, please delay elective treatment for 14 days, then re-evaluate. Please call the office at 613-707-6768 to reschedule your appointment. 

Download Patient Screening Form

PATIENT INFORMATION
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Who Answered:*
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IN CASE OF EMERGENCY
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SCREENING QUESTIONS
Do you have a fever of have you felt hot or feverish anytime in the last two weeks?*
Do you have any of these symptoms: Dry cough, shortness of breath, difficulty breathing or swallowing, pink eye, digestive issues, sore throat, runny nose, chills, fatigue, headache, muscle aches*
Have you experienced a recent loss of smell or taste?*
Have you returned from travel outside of Canada in the last 14 days?*
Tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?*
Any "YES" response must be discussed with the managing dentist immediately.

PATIENT ACKNOWLEDGEMENT: COVID-19 PANDEMIC EMERGENCY DENTAL RISK
Please read the patient acknowledgement and sign that you agree. I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. 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. For this reason, it is recommended to stay home and avoid close contact with other people when at all possible. I understand the federal and provincial government have asked individuals to maintain social distancing of at least 2 metres (6 feet) and I recognize it is not possible to maintain this distance while receiving dental treatment. I understand that oral surgery/dental procedures can create water and/or blood spray, which is one important 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 visits of other patients, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have an elevated risk of contracting and spreading the novel coronavirus simply by being in the dental office. I confirm that I do NOT have any TWO OR MORE of the following symptoms of COVID-19: fever, new or worsening cough, sore throat, runny rose or headache. I confirm that I have not tested positive for COVID-19 and/or this is not currently a period where I required to self-isolate for 14 days. IF I DEVELOP ANY SYMPTOMS OF COVID-19 WITHIN 14 DAYS OF MY APPOINTMENT, I WILL CONTACT THE OFFICE. I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have emergency surgical/dental treatment completed during the COVID-19 pandemic.
I acknowledge the patient acknowledgement above*
I certify that I have read, understand and accurately completed the personal, medical and dental histories, to the best of my knowledge and have no knowingly omitted any information. This information has been reviewed with me, and I have had the chance to ask questions and to receive answers regarding any medical/dental histories. As be required, I consent to my physician being contacted regarding any specific medical questions. I authorize the dentist to perform necessary diagnostic procedures and treatment, including anaesthetic, as required, to achieve the proper level of dental care. I understand that I am financially responsible to the dentist for the dental services provided even if my insurance coverage may not be all inclusive.
GENERAL CONSENT STATEMENT
CDA NET AUTHORIZATION
I authorize release, to my insuring company plan administrator, the information contained in claims submitted electronically.I understand I am responsible for my account and knowing my insurance policy.
PATIENT AWARENESS/ACKNOWLEDGEMENT LETTER FOR OFFICE POLICIES
We often have people waiting for dental treatment. We request 2 business days notice for cancellations, and we reserve the right to dismiss you as a patient if you consistently miss appointments. If you have outstanding treatment, please seek another dental office
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