Lee Dental Patient Screening Form

    OFFICE USE ONLY 僅限辦公室使用

    Use this form to screen patients before their appointment and when they arrive for their appointment.
    Staff screener:   
    Patient Name:  
    Patient age:  
    Who answered:    
    Contact Method:    
    Identify yourself and explain the purpose of the call, which is to determine whether there are any special considerations for their dental appointment. Have the patient answer the following questions.


    Patient Name*:  



    Is this form filled before the appointment or in the office?

    Have you had close contact with anyone with acute respiratory Illness travelled outside of Ontario in the past 14 days?

    Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?

    Do you have any of the following symptoms:

    • Fever 發燒

    • cough 咳嗽

    • Shortness of breath/Difficulty breathing 呼吸困難

    • Sore throat 喉嚨痛

    • Difficulty swallowing 吞嚥困難

    • Decrease or loss of sense of taste or smell 下降/失去味覺或嗅覺

    • Chills 發冷

    • Headaches 頭痛

    • Unexplained fatigue/malaise/muscle aches (myalgias) 肌肉疼痛

    • Nausea/vomiting, diarrhea, abdominal pain, Pink eye (conjunctivitis) 反胃,嘔吐,腹瀉,腹痛,眼部充血

    • Runny nose/nasal congestion without other known cause 非過敏性鼻炎

    Are you 70 years of age or older, experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?

    Patient Acknowledgement:

    COVID-19 Pandemic Dental Risk

    Please read the patient acknowledgement below, and initial or sign in all areas indicated.



    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.

    I understand the federal and provincial authorities have asked individuals to maintain social distancing of a least two (2) meters (six (6) feet) and 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 way that the novel coronavirus can spread. I understand that 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 the novel coronavirus simply by being in the dental office.

    I confirm that I do NOT have any TWO OR MORE or the following symptoms of COVID-19: (i) fever, (ii) new or worsening cough, (iii) sore throat, (iv) runny nose or (v) headache.

    If I received COVID-19 test results in the past three (3) months, the last results I received were negative. If applicable, approximate date of test

    I confirm that I am not waiting for the results of a test for COVID-19.

    I confirm that this is not currently a period during which public health authorities required I self-isolate

    checked*  I verify the information I have provided on this form is truthful and complete. I knowingly and willingly consent to have surgical/dental treatment completed during the COVID-19 pandemic. 我確認以上信息的真實性和完整性,並同意在新冠病毒大流行期間接受牙醫治療。

    Print Your Name*:       Date*:  

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