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PATIENT CONSENT AND QUESTIONNAIRE PERTAINING TO GUIDELINES FOR COVID19 PANDEMIC
PLEASE NOTE: WHEN YOU ARRIVE FOR YOUR APPOINTMENT DO NOT COME IN TO THE OFFICE. PELASE CALL US AND LET US KNOW OF YOUR ARRIVAL AND WAIT IN YOUR CAR TO BE INVITED TO COME IN. A MEMBER OF OUR STAFF WILL COME OUT TO TAKE YOUR TEMPERATURE.
PLEASE ANSWER THE FOLLOWING QUESTIONS AND SEND A REPLY 2 HOURS BEFORE YOUR APPOINTMENT

1. HAVE YOU OR ANY MEMBER IN YOUR HOUSEHOLD EXPERIENCED THE FOLLOWING:

Fever, Cough

Yes
No

Difficulty to breath

Yes
No

Body ache

Yes
No

Vomiting, nausea, diarrhea

Yes
No

IF YOU ANSWERED YES TO ANY OF THE QUESTIONS PLEASE PROVIDE DETAILS:

2. WITHIN PAST 30 DAYS HAVE YOU BEEN TRAVELLING ANYWHERE OUTSIDE OF CANADA OR BETWEEN PROVINCES IN CANADA:

Yes
No

3. HAVE YOU BEEN ADVISED TO BE ON QUARANTINE (ISOLATION)

Yes
No
IF YES PLEASE PROVIDE DETAILS:

4. HAVE YOU OR ANY MEMBER OF YOUR HOUSEHOLD BEEN DIAGNOSED WITH COVID 19:

Yes
No
IF YES, PLEASE PROVIDE DETAILS:
certify that I have read and fully understand all of the above and have been fully informed of the nature of the bone grafting treatment along with possible risks and complications and by signing below hereby consent to treatment.

PATIENT SIGNATURE:

К сожалению, ваш браузер не поддерживает данную функцию.
Мы рекомендуем вам обновить ваш браузер или установить другой.

DATE:

______________

DOCTOR SIGNATURE:

К сожалению, ваш браузер не поддерживает данную функцию.
Мы рекомендуем вам обновить ваш браузер или установить другой.

DATE:

______________

FOLLOWING 2 WEEKS AFTER YOUR APPOINTMENT TO OUR OFFICE, PLEASE ADVISE US IF YOU OR ANY MEMBER OF YOUR FAMILY TESTED POSITIVE WITH COVID19 VIRUS.
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