Concourse Dental - Covid-19 Screening Form

COVID-19 Pandemic Patient Disclosure Form Prior to Appointments

Before receiving treatment, we would like to request the following information from you in accordance to safe guidelines from Public Health, our regulatory College, and the government. We appreciate your candor, time and understanding.

(Please note: a weak or compromised immune system, including from diabetes, asthma, chronic obstructive pulmonary disease, or any other issues with your lungs, cancer treatment, radiation, chemotherapy or any prior or present medical conditions, may put you at a higher risk of contracting COVID-19. We may advise you to consider rescheduling your appointment to a later, safer date.)

It is also very important that you disclose to this office any chance of having been exposed to COVID-19, or whether you have or are experiencing any signs or symptoms associated with the COVID-19 virus. It is for your health and safety, and that of our staff.

You will also receive a copy of the completed form in your email.

* Required.

Select a Date *

Name *

Email *

Please check the “Yes” or “No” button to answer the following questions. Thank you.

1. Do you have a new or recent fever or do you feel warmer than usual? *

Yes No

2. Have you recently felt short of breath doing routine activities? (walking, stairs, groceries) *

Yes No

3. Do you have a new dry cough? *

Yes No

4. Do you have a runny nose? *

Yes No

5. Have you recently noticed any change in taste sensations? *

Yes No

6. Have you recently lost your sense of smell, or do you have a lower sense of smell? *

Yes No

7. Do you have a sore throat? *

Yes No

8. Have you been in contact with someone who has tested positive for COVID-19? *

Yes No

9. Have you tested positive for COVID-19? *

Yes No

If you have tested positive for COVID-19, when?

Enter date.

10. Have you traveled outside Ontario or Canada in the last 14 days by any means? *

Yes No

11. Have you been in a crowd of greater than 10 people in the last 14 days? *

Yes No

12. Are there any other medical conditions you need to tell us about? *

Yes No

If your answer is yes to question 12, please briefly explain.

I fully understand and acknowledge the above information and have provided to The Concourse Dental Centre any conditions about my health which may result in a compromised immune system.

By clicking on the agree button and submitting this form, I acknowledge that my answers above are true and accurate.