Patient Screening Form

Screener Information

(Please Leave Blank For Clinic Staff to Complete)

Patient Information

Who Answered?

A dental team member will contact you and identify themselves and will then explain the purpose of the call before your appointment. The reason for this will be to determine whether there are any special considerations for your dental appointment. Please answer the following questions.

Contact Method

Screening Questions

Do you have a fever or have felt hot or feverish anytime in the last two weeks?

Patient temperature at appointment. If elevated, provide mask to patient.

Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose?

Have you experienced a recent loss of smell or taste?

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

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

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

Are you over the age of 60 and have any underlying health conditions?

Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?

Any "Yes" response must be discussed with the managing dentist immediately.