{"id":6446,"date":"2020-05-17T13:05:22","date_gmt":"2020-05-17T16:05:22","guid":{"rendered":"https:\/\/www.bouctouchedental.ca\/screening"},"modified":"2023-06-01T23:37:51","modified_gmt":"2023-06-02T02:37:51","slug":"screening","status":"publish","type":"page","link":"https:\/\/www.bouctouchedental.ca\/fr\/screening","title":{"rendered":"Formulaire de d\u00e9pistage des patients"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_5 1_5 fusion-one-fifth fusion-column-first\" style=\"--awb-bg-size:cover;width:20%;width:calc(20% - ( ( 4% + 4% ) * 0.2 ) );margin-right: 4%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_3_5 3_5 fusion-three-fifth\" style=\"--awb-bg-size:cover;width:60%;width:calc(60% - ( ( 4% + 4% ) * 0.6 ) );margin-right: 4%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f5732-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"5732\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/fr\/wp-json\/wp\/v2\/pages\/6446#wpcf7-f5732-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"5732\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.6\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f5732-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<h3>Patient Screening Form\n<\/h3>\n<p>Please fill out this mandatory screening form based on the new guidelines established by the NB Dental Society.\n<\/p>\n<div class=\"contact\">\n\t<p><label> Your Name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span> <\/label>\n\t<\/p>\n<\/div>\n<div class=\"contact\">\n\t<p><label> Your Email<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span> <\/label>\n\t<\/p>\n<\/div>\n<div class=\"questions-wrap\">\n\t<div class=\"question-wrap\">\n\t\t<div class=\"question\">\n\t\t\t<p>1. Do you have TWO (2) of the following s symptoms that are not related to a known pre-existing condition: A fever anytime in the last two weeks? Cough? Sore throat? Runny nose? Diarrhea? Headache? Loss of smell\/taste? Fatigue\/exhaustion? Muscle pain? Children: Any purple markings on fingers\/toes?\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"answer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"fever\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"fever\" value=\"YES\" \/><span class=\"wpcf7-list-item-label\">YES<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"fever\" value=\"NO\" \/><span class=\"wpcf7-list-item-label\">NO<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"question-wrap\">\n\t\t<div class=\"question\">\n\t\t\t<p>2. Have you been advised by Public Health, a health care provider or a peace officer that you are currently required to self-isolate?\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"answer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"symptoms\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"symptoms\" value=\"YES\" \/><span class=\"wpcf7-list-item-label\">YES<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"symptoms\" value=\"NO\" \/><span class=\"wpcf7-list-item-label\">NO<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"question-wrap\">\n\t\t<div class=\"question\">\n\t\t\t<p>3. Are you waiting for a Covid-19 test or Covid-19 test results AND have been told you need to self-isolate?\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"answer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"smell\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"smell\" value=\"YES\" \/><span class=\"wpcf7-list-item-label\">YES<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"smell\" value=\"NO\" \/><span class=\"wpcf7-list-item-label\">NO<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"question-wrap\">\n\t\t<div class=\"question\">\n\t\t\t<p>4. Have you travelled outside of the province within the last 14 days? (unless exempt from selfisolation)?\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"answer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"contact\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"contact\" value=\"YES\" \/><span class=\"wpcf7-list-item-label\">YES<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"contact\" value=\"NO\" \/><span class=\"wpcf7-list-item-label\">NO<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"question-wrap\">\n\t\t<div class=\"question\">\n\t\t\t<p>5. Has an individual in your household returned from outside of the province in past 14 days for any reason, and now someone within the household has developed one or more symptoms of Covid-19 as listed above?\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"answer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"travel\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"travel\" value=\"YES\" \/><span class=\"wpcf7-list-item-label\">YES<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"travel\" value=\"NO\" \/><span class=\"wpcf7-list-item-label\">NO<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"question-wrap\">\n\t\t<div class=\"question\">\n\t\t\t<p>6. Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any autoimmune disorder?\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"answer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"age\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"age\" value=\"YES\" \/><span class=\"wpcf7-list-item-label\">YES<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"age\" value=\"NO\" \/><span class=\"wpcf7-list-item-label\">NO<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Send\" \/>\n<\/p><div class=\"fusion-alert alert custom alert-custom fusion-alert-center wpcf7-response-output fusion-alert-capitalize awb-alert-native-link-color alert-dismissable awb-alert-close-boxed\" style=\"--awb-border-top-left-radius:0px;--awb-border-top-right-radius:0px;--awb-border-bottom-left-radius:0px;--awb-border-bottom-right-radius:0px;\" role=\"alert\"><div class=\"fusion-alert-content-wrapper\"><span class=\"fusion-alert-content\"><\/span><\/div><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><\/div>\n<\/form>\n<\/div>\n<div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_5 1_5 fusion-one-fifth fusion-column-last\" style=\"--awb-bg-size:cover;width:20%;width:calc(20% - ( ( 4% + 4% ) * 0.2 ) );\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-6446","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.7 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Formulaire de d\u00e9pistage des patients - Centre Dentaire Bouctouche<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.bouctouchedental.ca\/fr\/screening\" \/>\n<meta property=\"og:locale\" content=\"fr_FR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Formulaire de d\u00e9pistage des patients - 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