Pre-Appointment COVID-19 Screening Intake Form

Patient Name:*

1. Have you had close contact with anyone with acute respiratory Illness or travelled outside of Ontario in the past 14 days?

Yes
No

2. Do you have a confirmed case of COVID-19 or have you had close contact with a confirmed case of COVID-19?

Yes
No

3. Do you have any of the following symptoms: Fever

Yes
No

Worsening chronic cough ?

Yes
No

New onset of cough ?

Yes
No

Shortness of breath ?

Yes
No

Difficulty breathing ?

Yes
No

Sore throat ?

Yes
No

Difficulty swallowing

Yes
No

Decrease or loss of sense of taste or smell ?

Yes
No

Chills ?

Yes
No

Headaches ?

Yes
No

Unexplained fatigue/malaise/muscle aches (myalgias) ?

Yes
No

Nausea/vomiting, diarrhea, abdominal pain ?

Yes
No

Pink eye (conjunctivitis) ?

Yes
No

Runny nose/nasal congestion without other known cause ?

Yes
No

4. If you are 70 years of age or older, are you experiencing any of the following symptoms:

Not applicable

delirium ?

Yes
No

unexplained or increased number of falls?

Yes
No

worsening of chronic conditions?

Yes
No

I understand that Provincial Health Services has asked individuals to maintain social distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive dental treatment.

I verify that I have not been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self- isolate by Provincial Health, the CDC or any other governmental health agency.

I verify that the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have my dental treatment completed during the COVID-19 pandemic. *(Signature)