Patient Pre-Screening

Patient Name*

First Last

Email*

1. Do you have a fever (greater than 38°C) or fever like symptoms, chills, Sweats or a new or worsening cough?*

Yes
No

2. Are you or a household member waiting for COVID-19 test results?*

Yes
No

3. Have you or a household member tested positive for COVID-19?*

Yes
No

4. In the past 48 hours have you had, or are you currently experiencing: Fever OR Cough (new or worsening), OR, Two or more of the following symptoms (new or worsening): • Sore throat • Runny nose/nasal congestion • Headache • Shortness of breath*

Yes
No

5. Have you been in close contact, without PPE, with someone who is a suspected or confirmed COVID-19 patient, within the last 14 days?*

Yes
No

6. Have you been to any of the potential COVID exposure locations listed at http://www.nshealth.ca/covid-exposures during the potential exposure window.

If you did not review the list prior to starting this survey, please click the link at the top of this page and do so before proceeding.

Yes
No

7. Have you or a family member travelled outside of Atlantic Canada (Nova Scotia, New Brunswick, Prince Edward Island, Newfoundland and Labrador) by air, car, bus or otherwise, in the past 2 weeks?*

Yes
No

1. Pre-screening form MUST be completed (both accurately and honestly) at least two days prior to your appointment, and it is imperative that you inform us of any changes to your symptoms or risk factors for Covid-19. Patients who arrive for their scheduled appointment not having completed the pre-screening form will not be allowed to enter the practice, must reschedule their appointment, and will be charged the applicable late cancelation fee.*

Acknowledged

2. Patients will be required to wear their mask at all times in our clinic with the only exception being during active dental/hygiene treatment. All patients are required to bring their own facial mask that covers both their mouth and nose with a good peripheral seal. If for medical reasons you can not wear a mask, we will require a doctor’s verification, and will be offering limited appointment availability. *We remind our patients that the Nova Scotia Health Authority continues to require that all people wear a mask in public spaces regardless of vaccination status.*

Acknowledged

3. All patients MUST use hand sanitizer as you enter the practice. A sanitization center has been set up directly outside the main clinic entrance.*

Acknowledged

4. We will limit the time patients spend in our waiting area and for this reason we will immediately guide patients into the treatment operatory whenever possible. Social distancing greater than 6 feet will be established if you are required to sit in the waiting room.*

Acknowledged

6. All patients will be required to rinse for 30 seconds with 1% Hydrogen Peroxide solution and expectorate back into the cup.*

Acknowledged

5. We ask that where possible, admin documentation be completed digitally/remotely prior to and following your appointments. A touchless payment system will be provided at the reception area.*

Acknowledged

I acknowledge the above to be true, and that I will inform Dr. Ryan Thomas Dentistry of any changes prior to my scheduled appointment*

Signature

Dr. Ryan Thomas Dentistry

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