Please complete our COVID-19 pre-screening form
Patient First & Last Name
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Have you travelled outside of Canada in the past 14 days?
Yes
No
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Have you tested positive to COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
Yes
No
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Do you 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
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Are you 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/nasal congestion without other known cause
Yes
No
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If you are 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?
Yes
No
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I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatments completed during the COVID-19 pandemic.
Acknowledge
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Confirm your email address:
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(Please click submit only once)