COVID-19 Patient Pre-Screening Questionnaire

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In order to safe-guard our dental office, and the rest of our community, we ask that you complete this form prior to arriving at our office. If you are experiencing any COVID-19 symptoms, we politely ask that you do not come to our office at this time.

Email *

Patient Name *

I understand that COVID-19 has a long incubation period, during which carriers of the virus may not show symptoms and still be contagious. *

Yes

Do you have a fever, or have you been feverish at any point in the last 10 days? *

Yes

Do you have any of the following symptoms: New or worsening cough? New or worsening shortness of breath? Headache? Sore throat? Runny nose? New loss of taste and/or smell? *

Yes

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

Yes

Have you returned for travel outside of Canada in the last 14 days? *

Yes

Have you returned from travel within Canada from a location known to be affected with COVID-19 in the last 14 days? *

Yes

Is your work place considered high risk? *

Yes

Are you over the age of 65 and/or have pre-existing health conditions related to the following: Heart disease, lung disease, diabetes, chronic kidney or liver disease, or immunocompromised? *

Yes

Have you attened any large group functions in the last 14 days? [ Functions over 10 people] *

Yes

Patient Electronic Signature *

Option 1

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A copy of your responses will be emailed to the address you provided.

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