County Court Dentistry

Use this form to screen patients before their appointment and when they arrive for their appointment.

Staff screener

Patient Name

Patient age

Who answered

Patient

Other (specify)

Contact Method

Phone

Other

Have you travelled outside of Canada in the past 14 days?

Pre-Screen
Yes No

In-Office
Yes No

Have you tested positive to COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

Pre-Screen
Yes No

In-Office
Yes No

Do you have any of the following symptoms

• Fever
• New onset of cough
• Worsening chronic cough
• Shortness of breath
• Difficulty breathing
• Sore throat
• 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)
• Runny nose/nasal congestion without other known cause

Pre-Screen
Yes No

In-Office
Yes No

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

Pre-Screen
Yes No

In-Office
Yes No

1. Any "Yes" response must be discussed with the managing dentist immediately.

2. Tell the patient when they arrive at the office, they will be asked to:

Sanitize their hands
Answer the questions again
Have their temperature taken
Complete a form acknowledging the risk of COVID-19

3. Advise the patient:

Only patients are allowed to come to the office.
If possible, to wait in their car until their appointment, call the office when they arrive

Patient Screening Form

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