Please fill out the following Covid-19 patient screening form before visiting our office for your appointment.

Name *

First

Last

Email *

Phone *

Have you tested positive for COVID-19 or are you awaiting results for a COVID-19 test? *

Yes
No

Do you have a fever or have felt hot or feverish anytime in the last two weeks? *

Yes
No

Do you have any of the following: dry cough, shortness of breath, difficulty breathing, sore throat, runny nose, sneezing, post-nasal drip? *

Yes
No

Have you experienced a recent loss of smell or taste? *

Yes
No

Even if you do not currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days? *

Yes
No

Have you, in the last 14 days, come in contact with any confirmed COVID-19 positive patients or persons self-isolating because of a determined risk for COVID-19? *

Yes
No

Have you returned from travel outside of Canada in the last 14 days? *

Yes
No

Have you returned from travel within Canada from a location known to be affected with COVID-19? *

Yes
No

Is your workplace considered high risk for COVID-19? *

Yes
No

Are you over the age of 70? *

Yes
No

Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? *

Yes
No

If there is a positive response to any of these, we would recommend discussing with the dentist and team before proceeding with any elective dental treatment.

Are there any other conditions you would like to report?

Temperature Check

If your oral temperature is 37.8°C (100°F) or above, please reschedule your appointment. Note, your temperature will be taken once you enter the clinic.

By clicking here and signing my name below, I confirm that I know there are categories of people who are considered to be at high risk. I understand the high-risk category factors are being 65 years of age or older, heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder. If I (or the patient I am completing this form for) are in one of these categories I have chosen to proceed with my (or the patients) appointment knowing the risk to my (or the patients) health if I (or the patient) develop COVID-19. I confirm that if there are any changes to the above answers from the time I complete this form to the time of my (or the patient in the case of a minor) appointment, I will let the office know. *

I verify the information I have provided on this form is truthful and accurate.

Signature

Today's Date *

Name