Dental Appointment COVID Prescreening
We are excited to see you tomorrow at your appointment. Prior to your appointment we require that you complete our COVID prescreening questionnaire to ensure there are no signs and symptoms of COVID19 prior to to the arrival of your appointment.
Date of Appointment
I understand that the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. For this reason, I understand that the federal and provincial authorities have recommended that Ontarians stay home and avoid close contact with other people when at all possible.
I confirm that I am not currently presenting any of the following symptoms of COVID-19 identified by Ontario Public Health as follows; (Check boxes to confirm you DO NOT have the following symptoms)
Fever > 38 Degrees
New cough or worsening chronic cough
Sore throat or painful swallowing
New or worsening shortness of breath
Loss of Smell/Taste
I confirm that I am NOT waiting for the results of a test for COVID-19.
I confirm that I have NOT travelled outside of the country in the last 14 days.
I confirm that to the best of my knowledge, I have NOT been around anyone that tested COVID positive in the last 14 days.
NO. I have not been in contact with anyone who has tested positive for COVID19.
YES. I have been in close contact with an individual who has tested positive.
I verify the information I have provided on this form is truthful and complete. I knowingly and willingly consent to have dental hygiene treatment completed during the COVID-19 pandemic.
Please do not arrive early for your appointment tomorrow unless asked to arrive early. Please wait outside the clinic until advised to come inside. You will be required to wear a mask inside the clinic while not receiving dental treatment. Upon arrival tomorrow, you will also be asked to fill out a complete COVID consent form prior to beginning dental treatment.
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