Smile Care Dental COVID Patient Self Screening
As per Public Health Guidelines MASKS ARE still REQUIRED in health care facilities.
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First Name *
Last Name *
Email *
Phone Number *
1. Are you fully vaccinated against COVID-19 and/ or aged 11 or younger? ( The answer to this question will not impact your ability to access dental care) *
2. Are you currently experiencing: severe difficulty breathing, severe chest pain, feeling confused/ unsure where you are, losing consciousness? *
3. In the last 14 days, have you travelled outside of Canada? ( select "No" If exempt from federal quarantine requirements as directed by the border agent at your point of entry ) *
4. In the last 5 days have you experienced any of these symptoms? ( Choose any/all that are new, worsening, and NOT related to other known causes or conditions you already have.) *
Required
5. Do you live with someone who is currently isolating because of a positive COVID-19 test OR you live with someone who is currently isolating because of COVID-19 symptoms OR you live with someone who is isolating while waiting for COVID-19 test results?
Clear selection
6. In the last 5 days, have you tested positive on a rapid antigen test, molecular test, or home-based self-testing kit?
Clear selection
7. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?
Clear selection
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