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.