Patient First & Last Name



Next >

Did the patient travel outside of Canada in the past 14 days?

Yes

No


< Prev Next >

Has the patient tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

Yes

No


< Prev Next >

Does the patient have any of the following symptoms?
. Fever
. New onset of cough
. Worsening chronic cough
. Shortness of breath
. Difficulty breathing
. Sore throat
. Difficulty swallowing
. Chills
. Headaches

Yes

No


< Prev Next >

Is the patient experiencing any of the following?
. Decrease or loss of sense of taste or smell
. Unexplained fatigue/malaise/muscle aches (myalgias)
. Nausea/vomiting, diarrhea, abdominal pain
. Pink eye (conjunctivitis)
. Runny nose or nasal congestion without other known cause

Yes

No


< Prev Next >

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

Yes

No


< Prev Next >

I verify the information I have provided on this form is truthful and accurate. I consent to have dental treatment performed during the COVID-19 pandemic.

Acknowledge


< Prev Next >

Confirm your email address:

< Prev
(Please click submit only once)