COVID-19 Pre-screening Form
Please remember to wear a mask when visiting our office!
Phone Number - preferably a cell number
These questions must be answered honestly under penalty of law. If you answered YES to any of the questions 1 through 3 then please submit this form and call our office (902 835-1031). Please answer YES or NO to each of the following questions. Please note: If there will be an attendant (maximum 1 person) with the patient these answers will apply to both of you.
1) Is anyone in your household experiencing cold or flu like symptoms?
2) Have you or anyone in your household been in close personal contact with a suspected or confirmed COVID-19 patient within the past 2 weeks?
Explain any YES answers in the box below:
Signature: By writing your name in the box below, you accept that due to the characteristics of the novel coronavirus, and the nature of dental procedures, you could have an elevated risk of contracting COVID-19. I understand, to help minimize the risk to patients and staff. Hammond Dental Centre is following the Return to Practice Guidelines set forth by the Provincial Dental Board and the Chief Medical Officer of Nova Scotia.
Signature can be written with your mouse or your finger.
Please advise the office (902 835-1031) if any of these answers change before your appointment time.
Should be Empty: