COVID-19 Patient Screening Form

Prior to all dental visits, we are required to complete this form prior to any patient visiting the office. These questions will be asked prior to scheduling an appointment and when the patient arrives at the office for their appointment.

  • Any “YES” response will be discussed with the Dentist upon arrival.
  • Masks are mandatory before entering the office.
  • Only patients should be entering the office unless a parent or support person is needed.
  • To help with social distancing, patients should wait in their car until 5 minutes before the scheduled appointment time then you may enter the office.
  • No magazines, newspapers or children’s toys will be available.
  • Upon arrival at the office, all patients will be asked to:
    • Wear a mask until seated in a dental chair.
    • Sanitize hands with the provided hand sanitizer.
    • Answer the screening questions.
    • Temperature check with a touch-free thermometer.
Do you have a fever or have felt hot or feverish anytime in the last two weeks?

Have you had close contact with anyone with acute respiratory illness or traveled outside of Canada in the past 14 days?

Have you had a confirmed case of COVID-19, been tested for COVID-19 and awaiting test results or had close contact with a confirmed case of COVID-19 without appropriate PPE?

(Over the Age of 70 only) Have you experienced any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?

Patient Acknowledgement of Treatment

The Novel Coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand the virus can have an extended incubation period during which carriers of the virus may not show symptoms and still be contagious. It is possible to contract the virus in any setting but that the risk during dental treatment can be higher due to the nature of treatment and proximity of people during care. The Team at TechTown Dentistry will always follow protocols to help minimize this risk and follow guidelines by our regulatory bodies to ensure the best safety practices. I understand the above information and consent to have dental treatment completed during the COVID-19 pandemic.