Dental Practice Ottawa

Teeth Removal in Downtown Ottawa

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Patient Screening Form

Use this form to screen patients before their appointment

Staff screener:

Patient Name::*

Date of screening:*

Have the patient answer the following questions.

Q1. Are you immunocompromised?*

Yes

No

Third Choice

Q2: Do you have any of these symptoms? Choose any or all that are new, worsening and not related to other known causes or conditions 2

Fever and/or chills tiredness Cough or barking cough Shortness of breath nose Decrease or loss of taste or smell
Muscle aches/joint pain Extreme
Sore throat
Runny or stuffy/congested
Headache
Nausea, vomiting and/or diarrhea
Abdominal pain
Pink eye

Question 2*

Yes

No

03: Have you been told (by a doctor, health care provider, public health unit, federal border agent. or other government authority} that you should currently be quarantining,isolating or staying at home?*

Yes

No

Q4: In the last lO days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self-testing kit?*

Yes

No

Any “yes” response (other than Q1) must be discussed with the managing dentist immediately. Tell the patient that when they arrive at the office, they will be asked to:

Sanitize their hands
Have their temperature taken (depending on the dental office*s policies).

Factors such as old age. diabetes and end-stage renal disease are generally not considered immunocompromised. Examples of being immunocompromised include individuals:

undergoing cancer chemotherapy
with untreated HIV infection with CD4 T lymphocyte count less than 200
with combined primary immunodeficiency disorder
on prednisone medication - more than 20 mg per day {or equivalent} for more than 14 days
on other immune suppressive medications.

* Select “No” if all of these apply:

you do not have a fever, and
your sympLoms have been improving for 24 hours (4B hours if you have nausea, vomiting, and/or diarrhea)

General Dentistry

Our dentists are firm believers in the old axiom of an ounce of prevention being worth a pound of cure. That’s why we emphasize the importance of proactive oral hygiene, regular dental check-ups, and addressing any dental issues as soon as they come up.

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Cosmetic Dentistry

Advances in technique and technology have allowed the aesthetic appeal of cosmetic dentistry to shine through. At Constitution Dental, we are proud to provide teeth whitening services, porcelain veneers, composite bonding, and complete smile makeovers to give you the beautiful smile you deserve.

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Invisalign

Invisalign® treatments consist of a series of transparent trays that gradually shift your teeth into their optimal position. Sometimes referred to as “clear braces,” Invisalign has helped many teens and adults attain perfectly straight teeth without painful metal brackets.

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Restorative Dentistry

The goal of restorative dentistry is to do exactly what the name implies: to restore the teeth to their original or optimal condition. At Constitution Dental, we are proud to offer dental implants, complete and partial dentures, dental crowns and bridges, and other restorative dentistry solutions.

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Dental Practice Ottawa

Patient Screening Form

General Dentistry

Cosmetic Dentistry

Invisalign

Restorative Dentistry

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