Health Screening Questionnaire

* Marked fields are required.

PATIENT INFORMATION

Name:*
Your Email*:
Cell Phone Number:

SCREENING QUESTIONS
Please check ANY that apply

I am waiting for COVID-19 test results or have been told to isolate.I have tested positive for COVID-19 in the past 10 days.

Do you have any of the following symptoms:

Fever and/or chillsSore throatRunny or stuffy/congested nose or sinusesOnset of new cough or worsening chronic coughShortness of breathDecrease or loss of sense of taste or smellHeadacheUnexplained fatigue/lethargy/malaise/muscle aches (myalgias)Nausea/vomiting, diarrhea or abdominal painLoss of appetitePink-eye

Medical History Update:

Please list all medications (prescription or over-the-counter), and any vitamins, herbal medicines, or supplements (include dosages) that you are taking.

Please list any hospitalizations or surgeries or visits to the emergency room since your last dental visit:

Is there anything else about your health that you want us to know?

PLEASE READ

Important information about your upcoming dental appointment:

• Masks are not required to enter the building, but highly recommended.

• Please check in with reception when you arrive.

• The waiting room is open but has limited seating. If you prefer to wait in your car until we are ready for you, call the office — (905) 689-0733 — or call or text to (365) 323-9332 when you arrive and we will communicate with you when your room is ready.

• Screening forms are required for patients, and anyone who will be in the treatment room with the patient (eg. Parent, caregiver).

• Our team members continue to mask and wear N95 respirators during dental procedures. We have air purifiers in our reception areas and in every treatment room. These rooms have doors which are closed during your appointment to ensure excellent air quality for you.

• Please contact us if you have any questions after your appointment.

Declarations:* I declare that the information provided is correct to the best of my knowledge, and
I have read and understand these procedures (revised May 11, 2023).

Your safety is our main priority! Thank you for your co-operation.