COVID In-Office Form
Please fill out this form prior to visiting the office.

Answers to this form will not impact your dental appointment.

This form is used to ensure we meet all safety standards and determine the type of PPE our employees should prepare for your appointment.
Name (Firstname, Lastname) *
Do you have a fever or have felt hot or feverish anytime in the last 10 days? *
Are you experiencing a new onset of cough or difficulty breathing? *
Are you experiencing any of the symptoms below (Select all that apply) *
Required
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 iwth COVID-19 in the last 14 days? *
Is your workplace considered high risk? *
Are you over the age of 65? *
Do you have any of the following: Heart Disease, lung disease, kidney disease, diabetes or any auto-immune disorder? *
Treatment Consent: Please be assured that our office has always met or exceeded the requirements set forth for sterilization and infection control from the RCDSO and PHO, and will continue to do so. However, it is possible to contract COVID-19 infection (or other communicable disease) in any public space. Our office will provide for socially distant appointment scheduling, and also has added a number of new technologies and techniques to the practice to enhance our level of safety. However, due to the nature of the dental treatments, social distance is not possible between the patient and clinical staff/doctor. Exposure to communicable disease is unlikely but possible. Clicking "yes" below indicates that the risks involved are accepted, and that consent is given for treatment to be provided by the office of R U Smiling dental staff. *
Required
Submit
Never submit passwords through Google Forms.
This form was created inside of rusmilingdental.com. Report Abuse