COVID-19 Pre-Screening Form

Name: Trischuk Dental Clinic
Address: 524 Broadway Street West, Yorkton, SK, S3N 0P3, Canada
Telephone: 306-782-1224

First and Last Name:*

I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show*

I have been made aware of the Saskatchewan Dental Association and College guidelines that under the current pandemic all non-urgent dental care is not allowed. Dental visits should be limited to the treatment of ongoing tissue bleeding, alleviate severe pain or infection or conditions that significantly inhibit normal operation of teeth and mouth, and issues that may cause anything listed above within the next 3 to 6 months.*

I confirm I am seeking treatment for a condition that meets these criteria.*

I confirm that I am not presenting any of the following symptoms of COVOID-19 identified by Saskatchewan Health Services:

Fever> 38C

Cough

Sore Throat

Shortness of Breath

I confirm that I am not currently positive for the novel coronavirus*

I verify that I have not returned to Saskatchewan from any country outside of Canada whether by car, air, bus or train in the past 14 days.*

I understand that any travel from any country outside of Canada, including travel by car, air, bus or train, significantly increases my risk of contracting and transmitting the novel coronavirus. Saskatchewan Health Services require self-isolation for 14 days from the date a person has returned to Canada.*

I understand that Saskatchewan Health Services has asked individuals to maintain social distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive dental treatment.*

I verify that I have not been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by Saskatchewan Health, the Communicable Disease Control or any other governmental health agency.*

LIST OF DENTAL TREATMENT*

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above listed emergency dental treatment completed during the COVID-19 pandemic

Name

First name*

Last name*

Date

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