Screening form COVID 19

Screening form COVID 19

For the health and safety of our community, declaration of illness is required. Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 symptoms.
Name

First Name Last Name
Birth date

Month Day Year
Please add your birth date
1. Are you required to be in isolation due to COVID-19?

YES NO
For situations in which isolation is required, see the"When should you isolate yourself (COVID-19)" section of the Quebec.ca website
2.Are you in the period between 5 and 10 days following your isolation of 5 days at home due to COVID-19?

YES NO
If you answered NO to all the questions: STATUS NOT AT RISK

If you answered YES to at least one of the 2 questions: SUSPECTED/CONFIRMED STATUS.

Consult with the dental professional before confirming the appointment
The person who completed the form must sign the form :

Patient Attendant
I acknowledge that the information I've given is accurate and complete.
Signature *

Clear
Date

Month Day Year
Date
Clinic Personnel Signature

Clear
Should be Empty: