COVID Pre-Screening Form

Our COVID pre-screening form requires you to confirm each question. If there is an area you are unable to answer or have questions regarding the contents, please contact the office as soon as possible to review.

519-622-1230

Patient Name*
First Last
Phone*
I confirm that I am NOT presenting any of the following symptoms of COVID-19 identified by the Ministry of Health and Public Health of Ontario:*
Fever > 38, new onset of cough or worsening of a chronic cough, shortness of breath, decrease or lost sense of taste or smell FOR ADULTS OVER THE AGE OF 18: unexplained fatigue/lethargy/malaise/muscle aches (myalgias) FOR CHILDREN UNDER THE AGE OF 17: nausea/vomiting and/or diarrhea
- I CONFIRM I DO NOT HAVE ANY OF THESE SYMPTOMS
I confirm that I have NOT tested positive for COVID-19 in the past 10 days:*
- I CONFIRM
I confirm that I have NOT been advised to self-isolate by Public Health:*
- I CONFIRM
I confirm that I have NOT been in close contact with a confirmed case of COVID-19 without wearing the appropriate PPE:*
- I CONFIRM
I confirm that I have not traveled anywhere outside of Canada within the last 14 days and have been asked to self-isolate:*
- I CONFIRM
I am aware that there is specific guidance for vaccinated vs unvaccinated individuals however, this is not applicable in a dental office as dental staff has to treat patients regardless of their vaccine status:*
- I CONFIRM
Hidden
Date
MM slash DD slash YYYY
Signature of Patient (or Parent)*
I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above-listed emergency or routine dental treatment completed during the COVID-19 pandemic.
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