Patient Acknowledgement and Wellness Form

Name*

First Last

Email*

Phone*

Date of upcoming appointment

Please read the following statements and indicate your agreement by checking the box beside each statement:

I understand there is currently a health pandemic associated with COVID-19 and the novel coronavirus.

I understand that oral surgery/dental procedures can create aerosols (droplets and sprays), and that there may be an elevated risk of contracting and spreading the novel coronavirus in a dental office.

I understand the College of Dental Surgeons of BC has strongly recommended that staff and patients continue to wear masks within common areas of dental practices.

Do you have a fever or have you felt hot or feverish anytime in the last five days.*

Yes
No

Do you have any of the following symptoms?*

Dry Cough
Shortness of Breath
Difficulty Breathing
Sore Throat
Loss of Smell or Taste
None of the Above

Please check all that apply

Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19 in the last five days?*

Yes
No

Patient Acknowledgement and Wellness Form

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