Patient Screening Form

Patient Screening Form
Please complete and return a copy of this form to the dental office at least 48 hours in advance of your scheduled appointment.
Name:*

First Name Last Name
Date of Birth: *

MonthDay Year
Date
1. Do you have a fever or have felt hot or feverish anytime in the last two weeks?*

YesNo
2. Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? Sneezing? Post-nasal drip?*

YesNo
3. Have you experienced a recent loss of smell or taste?*

YesNo
4. Have you been in contact with any confrmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?*

YesNo
5. Have you returned from travel outside of Canada in the last 14 days?*

YesNo
6. Have you returned from travel within Canada from a location known affected with COVID-19?*

YesNo
7. Are you over the age of 70?*

YesNo
8. Do you have any of the following: Heart disease, lung disease, kidney disease, diabetes orany auto-immune disorder*

YesNo
Patient Signature (or if Patient is a minor, Parents Signature)*

Clear
Patients Name*

First Name Last Name
Date*

MonthDay Year
Date
Should be Empty: