COVID-19 PRE-APPOINTMENT SCREENING FORM

Patient Name*

Date of Birth:*

MM

DD

YYYY

Has there been any change to your contact information?*

Yes
No

Please provide the updated contact information:*

Has there been any change to your health, including changes in medications?*

Yes
No

We request patients come to their appointment alone wherever possible. We do make exceptions for parents/guardians, caretakers or translators if absolutely necessary. Will you be coming alone to your appointment?*

Yes
No

***If someone will be attending the appointment, be sure to complete a pre-screening for them as well

Do you have a confirmed case of COVID-19 or have you had close contact with a confirmed case of COVID-19?*

Yes
No

Have you been in contact with any person self-isolating because of a determined risk for COVID-19?*

Yes
No

Have you had close contact with anyone with acute respiratory illness in the past 14 days?*

Yes
No

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

Yes
No

Do you have a fever (above 38C) or have felt hot or feverish anytime in the last two weeks?*

Yes
No

Do you have any of these symptoms:*

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

Yes
No

Are you over the age of 60?*

Yes
No

Have you experienced any of the following symptoms:*

Do you have any of the following: Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?*

Yes
No

*

I verify that the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have my dental treatment completed during the COVID-19 pandemic.