Smile Care Dental COVID Patient Self Screening
As per Public Health Guidelines MASKS ARE OPTIONAL.
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First Name *
Last Name *
Email *
Phone Number *
1. Are you currently experiencing: severe difficulty breathing OR severe chest pain OR feeling confused OR losing consciousness? *
2. Do you live in a long-term care home or retirement home? *
3. Are you immunocompromised? *
4. Do you have any of the following? 
( Choose any that are new, worsening, AND NOT related to other known causes or conditions you already have).

Select "None of the above" if BOTH of these apply: 
A) you do not have a fever and 
B) your symptoms have been improving for at least 24 hours (48 hours if you had nausea, vomiting and/or diarrhea)
5. Has a doctor, health care provider, public health unit or a government authority told you that you should currently be isolating or staying at home? *
6. In the last 10 days, have you tested positive for COVID-19 on any test? *
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