Please complete our COVID-19 pre-screening form

Patient First & Last Name



Next >
Have you travelled outside of Canada in the past 14 days?

Yes

No


< Prev Next >
Have you tested positive to COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

Yes

No


< Prev Next >
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


< Prev Next >
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


< Prev Next >
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


< Prev Next >
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


< Prev Next >
Confirm your email address:

< Prev
(Please click submit only once)