Surveypoint

Q1

First Name

Name*

Q2

Last Name

Name*

Q3

Sex*

Male

Female

Q4

Age*

Q5

Street Address

Address*

Q6

City

Address*

Q7

Occupation*

Q8

Contact Number*

Q9

Body Temperature (in Celsius)

Q10

In the past 14 days, have you or any member of your household, traveled to any areas with known cases of COVID 19?*

Yes

No

Q11

IF YES: Please state the exact location

Q12

In the past 14 days, have you or any member of your household has had any contact with any COVID-19 patient?*

Yes

No

Q13

Have you or any household member have any history of exposure to any COVID-19 biological material (eg. saliva)?*

Yes

No

Q14

Have you had any history of fever for the last 14 days?*

Yes

No

Q15

Have you had any symptoms in the last 14 days such as:*

Yes

No

Cough

Nausea

Diarrhea

Loss of taste

Difficulty breathing

Body Ache

Loss of smell

Fever

Q16

Urgent dental need question for the last 14 days such as:*

Yes

No

Uncontrolled dental/oral pain

Swelling

Bleeding

Infection

Trauma

Q17

Have you had any COVID-19 test?*

Yes

No

Q18

IF YES: When was the date of last test?

Q19

IF YES: When was the date of last test?

Q20

IF YES: What was the type of test used?

Q21

IF YES: What was the result of the test?

Positive

Negative

Not yet determined

Q22

INFORMED CONSENT*

Yes

No

I give my fill consent to have dental treatment done to me or my child(ren) in this time of pandemic caused by COVID-19 disease

I am aware that the viirus can be transmitted by contact through surfaces and that it can be infective for 5 to 72 hours. I am aware that this is impossible to identify who is probable, suspect or COVID-19 positive. Because of this, treatment options are limited to urgent and emergent care to protect me, other patients and the dental staff.

I recognize that the clinic is adhering to the strictest infection control protocols for my protection as such, I agree to cover the fees that this entails.

I fully understand the risk that because of the nature of the virus, by simply leaving my home, travelling to the clinic, the clinical procedures, and even by simply staying in the dental clinic, there is a chance of contracting the virus. Should I contract the virus, I hereby agree that I shall not hold the dental office liable.

I am also giving my consent that in accordance to the IATF rules, my identity shall be revealed for possible contract tracing for the interest and safety of the community.

Q23

Dental Clinic Covid 19 Triage -Form Fill

First Name

Last Name

Sex*

Age*

Street Address

City

Occupation*

Contact Number*

Body Temperature (in Celsius)

In the past 14 days, have you or any member of your household, traveled to any areas with known cases of COVID 19?*

IF YES: Please state the exact location

In the past 14 days, have you or any member of your household has had any contact with any COVID-19 patient?*

Have you or any household member have any history of exposure to any COVID-19 biological material (eg. saliva)?*

Have you had any history of fever for the last 14 days?*

Have you had any symptoms in the last 14 days such as:*

Urgent dental need question for the last 14 days such as:*

Have you had any COVID-19 test?*

IF YES: When was the date of last test?

IF YES: When was the date of last test?

IF YES: What was the type of test used?

IF YES: What was the result of the test?

INFORMED CONSENT*

For the good of the entire community, I am TRUTHFULLY answering the questionnaire and fully understand the informed consent form:

Dental Clinic Covid 19 Triage -Form Fill

First Name

Last Name

Sex*

Age*

Street Address

City

Occupation*

Contact Number*

Body Temperature (in Celsius) var statement=document.write(localStorage.getItem('total'));

In the past 14 days, have you or any member of your household, traveled to any areas with known cases of COVID 19?*

IF YES: Please state the exact location

In the past 14 days, have you or any member of your household has had any contact with any COVID-19 patient?*

Have you or any household member have any history of exposure to any COVID-19 biological material (eg. saliva)?*

Have you had any history of fever for the last 14 days?*

Have you had any symptoms in the last 14 days such as:*

Urgent dental need question for the last 14 days such as:*

Have you had any COVID-19 test?*

IF YES: When was the date of last test?

IF YES: When was the date of last test?

IF YES: What was the type of test used?

IF YES: What was the result of the test?

INFORMED CONSENT*

For the good of the entire community, I am TRUTHFULLY answering the questionnaire and fully understand the informed consent form:

Body Temperature (in Celsius)