COVID-19 PRE-APPOINTMENT SCREENING FORMPatient Name* First Last Date of Birth:* Month Day YearHas there been any change to your contact information?* Yes NoPlease provide the updated contact information:*Has there been any change to your health, including changes in medications?* Yes NoWe 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 wellScreening Questions1. Did you receive your final (or second) vaccination dose more than 14 days ago?* Yes No2. Do you have any of the following symptoms:* Fever and/or chills New onset of cough or worsening chronic cough Shortness of breath Decrease or loss of sense of taste or smell If adult >18 years of age: unexplained fatigue/ lethargy/ malaise/ muscle aches (myalgias) If child <18 years of age: nausea/vomiting, diarrhea I do not have any symptoms.3. Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating?* Yes NoIf you answered “NO” to Q1, please proceed to Q4 and Q5. Only answer Q4 and Q5 if you are not fully immunized.4. Have you travelled outside of Canada in the past 14 days?* Yes No5. Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?* 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.
