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About Us
Services
Gallery
Blog
Contact
FAQ
Covid-19 form
Patient Name :
Date of Appointment :
1. Did you/the patient have close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days?
YES
NO
2. Do you/the patient have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID -19?
YES
NO
3. Do you/the patient have any of the following symptoms: (please circle if any are YES)
-fever
-difficulty breathing
-shortness of breath
-new onset of cough
-worsening chronic cough
-sore throat
-difficulty swallowing
-chills
-decrease or loss of sense of taste or smell
-unexplained fatigue/malaise/muscle aches (myalgias)
-nausea/vomiting, diarrhea, abdominal pain
-runny nose/nasal congestion without other known cause
-headaches
-pink eye (conjunctivitis)
4. If you/the patient is over 70 years of age or older, and experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?
5. TEMPERATURE READING
I have answered truthfully and consent to continue care in the dental office today.
Send
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