Covid-19 Screening Form
Please answer and submit the following questions prior to your appointment at The Dental Smile Centre office
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Are you presenting with any of the following symptoms of COVOID-19 identified by Public Health Services:
*
Fever > 38°C
Chills
Sore Throat
Headache
Shortness of Breath
Difficulty Breathing
Flu-like Symptoms
Pink eye (conjunctivities)
Difficulty Swallowing
Cough (NEW OR WORSENING)
Runny Nose (NOT RELATED TO ALLERGIES)
Decrease or loss of sense of taste or smell
Unexplained fatigue/malaise/muscle aches
Nausea/vomiting, diarrhea, abdominal pain
NONE OF THE ABOVE
I confirm that I am not currently positive for Covid-19.
*
YES, I DO CONFIRM THAT.
I confirm that I am not waiting for the results of a laboratory test for Covid-19.
*
YES, I DO CONFIRM THAT.
I verify that I have not returned to Ontario from any country outside of Canada in the past 14 days and have been asked to isolate.
*
YES, I DO VERIFY THAT.
I verify that I have not been identified as a contact of someone who has tested positive for Covid-19 or been asked to self-isolate by Public Health.
YES, I DO VERIFY THAT.
I understand that Public Health has asked individuals to maintain social distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive dental treatment.
YES, I DO UNDERSTAND IT.
I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to having dental treatment at this time.
YES, I DO VERIFY THAT.
Submit the Form
Should be Empty: