Barrie Heights New Form

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Covid-19 Screening

Email Address

Full Name *

Date *

YYYY

I understand the novel coronavirus causes the disease known as covid-19. I understand it has a long incubation period during which carriers may not show symptoms and can still be contagious. Please Initial. *

Do you have any of the symptoms stated below? *

Cough, sore throat, loss of taste of smell, cold/flu symptoms, shortness of breath or difficulty breathing.

If yes to any of the above, please state what symptom : _____________________

I confirm that I am not positive for Coronavirus or waiting for lab results. Please initial to confirm. *

I confirm I have not traveled outside of Canada in the past 14 days and have not been in contact with anyone known to have traveled outside of Canada. Initial *

I am aware that some dental treatments may produce aerosol. I am aware that Barrie Heights Family Dentistry is following all protocols to reduce aerosols in the dental office. INITIAL

I verify that all of the information provided on this form is correct and truthful. I consent to dental treatment during the Covid-19 Pandemic. Please Sign name acting as signature. *

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