Screening Covid-19 - CDBF - Dentist in Saint-Bruno QC

Please carefully read the information below, check, date and sign where indicated.

If I develop symptoms or if I receive a positive Covid-19 test notification prior to my appointment, I undertake to notify the clinic as soon as possible. I understand that the clinic may then decide to reschedule my appointment.

On the day of my appointment, I understand that in order to be admitted to the treatment room, I will have to fill out this questionnaire again and my temperature will be taken.

I understand that the clinic has put in place special measures to maintain a safe work and care environment for the clinic's employees and patients in the context of the Covid-19 pandemic. I agree to (1) attend my appointment at the clinic alone, unless I absolutely need to be accompanied (e.g. young child), (2) wear a mask when I arrive at the clinic, (3) respect the safety instructions (e.g. washing my hands, wearing a mask, sneezing into my elbow...) that the clinic staff will give me.

I understand that I may be charged a fixed amount for the Covid-19 special measures that the clinic has put in place for my safety, the safety of employees and other patients.

By signing below, I confirm that I have read and understood this document and have answered the questions asked of me accurately and completely.

Courriel:

Date:

Signature of patient or legal representative

Covid-19 Screening Form

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