COVID-19 Screening Form

COVID-19 Screening Form
In an effort to minimize the risk of spread of COVID-19 and in accordance with the guidelines as set out by the Ontario Ministry of Health, the Royal College of Dentists of Ontario (RCDSO), and the College of Dental Hygienists of Ontario (CDHO):

All persons entering SHERWOOD DENTAL for an appointment or for any other reason must complete the following questions prior to your visit.

Thank you for your understanding and for helping STOP THE SPREAD.
Have you had a confirmed case of COVID-19 or have you had close contact with a confirmed case of COVID-19 in the last 4 weeks?*

YesNo
Have you travelled outside of Canada in the past 14 days?*

YesNo
Have you had any contact with anyone that has had or that you suspect of having acute respiratory illness or has traveled outside of Canada in the past 14 days?*

YesNo
Select if you currently are experiencing any of the below symptoms. Select the option "I DO NOT have any of these symptoms" if you do are not experiencing any of the below listed symptoms.*

FeverFlu-like symptomsNew onset coughWorsening chronic coughShortness of breathDifficulty breathingSore throatDifficulty swallowingDecrease or loss of sense of taste or smellChillsUnexplained fatigue / feeling of being unwell / muscle achesNausea/ vomiting / diarrhea / abdominal painRunny nose / nasal congestion without other known cause such as cold or allergyI DO NOT have any of these symptoms
By signing this document, I acknowledge that the answers I have provided above are true and accurate.
Patient’s (or legal guardian’s) Signature*

Your digital signature is as legally binding as a physical signature. Clear
Patient Name*

First NameMiddle NameLast Name
Date

MonthDayYear
Date
Should be Empty: