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COVID19 Patient Forms

COVID Health Questionnaire Form
Today's Date*
MM slash DD slash YYYY
Patient's Name*
First Last
Have you, your child, or others accompanying you to today’s appointment or other recent acquaintances tested positive for or been diagnosed as having COVID-19 or any other communicable disease?*
- Yes
- No
If yes, when?*
Do you, your child, or others accompanying you to today’s appointment or other recent acquaintances have any of the following symptoms:
Fever (defined as above 99.6 degrees)?*
- Yes
- No
Cough?*
- Yes
- No
Shortness of breath and/or trouble breathing?*
- Yes
- No
Persistent pain, pressure, or tightness in the chest?*
- Yes
- No
Other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?*
- Yes
- No
Recent loss of taste or smell?*
- Yes
- No
Have you/they traveled in the past 14 days to any regions affected by COVID-19?*
- Yes
- No
Any heart disease, kidney disease, diabetes, or autoimmune disorders?*
- Yes
- No
Consent*
I understand that if the answer to any of the above questions is yes, I will be asked to reschedule today’s appointment.*
Have you been vaccinated for COVID-19?*
- Yes
- No
Which dose(s)?*
- 1st Dose
- 2nd Dose
First and Last Name of person who completed this form*
First Last
Signature as acknowledgment of Covid Health Questionnaire*

Consent for Care Form
New patients complete Section 1 and 2. Existing Patients complete Section 2 only.
Patient name*
Section 1 (For New Patients only)
I, the legally authorized surrogate decision maker, do hereby request treatment at Bayside Dental & Orthodontics for the above listed patient. I authorize the attending office, staff of the procedures, including the administration of anesthetics, and the use of radiographs (X-rays) as may be recommended for my treatment. I also authorize the taking of images (including for example photographs, radiographs and films) and the creation of any other records (electronic and/or hard-copy) for the purpose of treatment, teaching, presentations, publications, research, or marketing. I understand that the records will be anonymized in order to protect my identity. Further, if applicable, I authorize the Bayside Dental & Orthodontics to release the required records to my dental insurance provider(s) in order to submit a pre-determination for treatment and to receive payment from the insurance provider for services rendered.
- Yes
- No
Signature as acknowledgement for Section 1
Section 2 (For All Patients)

Supplemental Informed Consent for Orthodontic Treatment in the Era of Covid-19
Thank you for your trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19 also known as “Coronavirus”, at any time or in any place. Be assured that we have always followed provincial regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so. Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our clinic, just as you might be at you’re your gym, grocery store or favourite restaurant. “Physical Distancing” has reduced the transmission of the Coronavirus. Although we have taken measures to provide distancing within our practice, due to the nature of the procedures we provide, it is not possible to maintain physical distancing between the patient, orthodontist, orthodontic staff and sometimes other patients at all times. Although exposure is unlikely, do you accept the risk and consent to treatment?*
- Yes
- No
Signature as acknowledgement for Section 2*

Consent*
- By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
Phone
This field is for validation purposes and should be left unchanged.

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BaysideDental&Orthodontics

Experienced dentists bringing the latest advancements and skills in oral care to Airdrie, Alberta.

info@airdriebaysidedental.com

airdriebaysidedental.com

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Dr. Suzanne Cziraki
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