Teal Umbrella Screening Form

1
Is your appointment today?* This field is required.
YES
NO
2
Name of the Patient* This field is required.
3
Email* This field is required.
example@example.com
4
Phone Number* This field is required.
Area Code
Phone Number
5
Date of Birth
Date
Year
Month
Day
6
I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand that 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, I understand that the federal and provincial authorities have recommended that Ontarians stay home and avoid close contact with other people when at all possible.* This field is required.
Clear
7
I understand the federal and provincial authorities have asked individuals to maintain social distancing of a least two (2) meters (six (6) feet) and I recognize it is not possible to maintain this distance while receiving dental treatment.* This field is required.
Clear
8
1. Did you have close contact with anyone with acute respiratory Illness or traveled outside of Ontario in the past 14 days?* This field is required.
YESNO
9
2. Do you have COVID-19 or had close contact with a confirmed case of COVID-19?* This field is required.
YESNO
10
3. Do you have one or any of the following symptoms?* This field is required.
Fever
New onset of cough
Worsening chronic cough
Shortness of breath
Difficulty breathing
Difficulty swallowing
Decrease or loss of sense of taste or smell
Chills
Headaches
Unexplained fatigue/malaise/muscle aches (myalgias)
Nausea/vomiting, diarrhea, abdominal pain
Pink eye (conjunctivitis)
None of the above
11
4. If the person is 70 years of age or older, are they experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions? * This field is required.
YESNO
12
Check your temperature and enter the result.
13
I confirm that I am not waiting for the results of a test for COVID-19.* This field is required.
Clear
14
I confirm that this is not currently a period during which public health authorities required I self-isolate for 14 days.* This field is required.
Clear
15
By signing below, I hereby release and agree to hold The Teal Umbrella Family Dental Healthcare, staff and doctors harmless from and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses, and compensation for damages or loss to myself and/or property that may be caused by any act, or failure to act of the office, or that may otherwise arise in any way in connection with any services received from The Teal Umbrella Family Dental Healthcare. I agree to release The Teal Umbrella Family Dental Healthcare, staff and doctors from any and all liability for the unintentional exposure or harm due to the Coronavirus (COVID-19)* This field is required.
Clear
16

You Should Fill Your Screening Form on The Morning of Your Appointment

Before 8AM !
17
Your COVID-19 screening result are subject to review by the dentist. Please remember to:

Wash your hands or use antiseptics

Not shake hands or contact physically

Wear facemasks or any suitable face covering before entering the building

You consent to having your temperature taken by one of our staff members before you enter our office.

When you reach the office, wait in your car, call the office, and you will get the instructions from the front desk of how to proceed.
Should be Empty: