COVID Screening Form

Welcome to our clinic!
Please take a few minutes to fill out this form as completely as you can.
If you have any questions we’ll be glad to help you.

Patient's First Name

Patient's Last Name

Birthday

Have you/they travelled outside of Canada in the past 14 days?

Yes

Have you/they tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Yes

Do you/they have any of the following symptoms? Fever, cough, worsening chronic cough, shortness of breath, difficulty breathing, sore throat, difficulty swallowing, decrease or loss of taste and smell, chills, headaches, unexplained fatigue/malaise/muscle aches, nausea/vomiting, diarrhea, abdominal pain, pink eye (conjuntivitis), runny nose or nasal congestion without other known cause?

Yes

If you/they are 70 years of age or older, are you/they experiencing any of the following symptoms? Delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?

Yes

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

Thanks for submitting!