Patient Screening Form

Leave this field blank

For the safety of our team, other patients, and yourself, please be truthful and candid in your answers.

If you have been exposed to a communicable disease, you may spread the disease to the dentist, dental staff, or other patients/parents in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission:

Patient Name:

Patient's age:

Who answered:

Patient

Other

Please specify

Contact Method:

Phone

Other

Please specify

Have you had close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days?

Yes

Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?

Yes

Do you have any of the following symptoms:

Fever

Yes

New onset of cough

Yes

Worsening chronic cough

Yes

Shortness of Breath

Yes

Difficulty Breathing

Yes

Sore Throat

Yes

Difficulty swallowing

Yes

Decrease or loss of sense of taste or smell

Yes

Chills

Yes

Headaches

Yes

Unexplained fatigue/malaise/muscle aches (myalgias)

Yes

Nausea/Vomiting, diarrhea, Abdominal pain

Yes

Pink eye (conjunctivitis)

Yes

Runny Nose/Nasal congestion without other known cause

Yes

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

Yes

- Any "yes" response will need to be discussed.
- When arriving to the office, you will be asked to:
- Sanitize your hands
- Answer the questions again
- Possibly of having your temperature taken
- Complete a form acknowledging the risk of COVID-19

- Please Note:
- Only patients are allowed to come to the office
- If possible, to wait in your car until their appointment, call the office when you arrive

FullName2 (optional)