Sydenham Family Dental | Biological & Comprehensive Dentistry

Auden Park Family Dentistry

COVID-19 In-office Screening Form

    Who answered these screening questions?

    Screening Questions

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

    2) Have you had close contact with a confirmed case of COVID-19 without wearing proper PPE?

    3) Have you had a COVID test performed? If “yes”, when was the test and what were the results?

    4) Do you have any of the following symptoms:

    • Fever

    • Pink eye (conjunctivitis)

    • 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

    • Runny nose/nasal congestion without other known cause

    5) Are you 70 years of age or older? If yes, do you have any of the following symptoms?

    • Delirium

    • Unexplained or increased number of falls

    • Acute functional decline

    • Worsening of chronic conditions?

    Any yes response: Dental care should be delayed for two weeks, please self-isolate and contact your primary care provider for guidance and/or visit your local COVID-19 testing centre — KFL&A – 613-354-8254 (9 am to 5 pm, Monday to Friday).

    Be advised:

    We will email a second COVID-19 Patient Screening Form, as well as a Patient Acknowledgement Form on the day of your appointment to be completed prior to arriving at your scheduled time. Please select “In-Office” for the second screening form.

    To bring your own mask or face covering

    Only patients with appointments are allowed to enter the clinical area.

    If parents of young children, or children of elderly parents want to accompany the patient, they must be pre-screened as well on a separate screening form
    Hygienists are hand scaling only — No polishing or use of ultrasonic scalers as per CDHO at this time

    When you arrive at the office, you will be asked to:

    Confirm that you’ve completed the Patient Acknowledgement Form & In-Office Pre-Screening Form

    Perform hand hygiene with alcohol-based hand rub (ie: hand sanitizer)

    Have your temperature taken

    Maintain physical distancing (2 metres)

    Keep your mask or face covering on at all times, except at the time of treatment

    Draw your signature or initials