COVID-19 Patient Screening Form
In an effort to reduce communal spread of COVID-19, and improve the health and safety of all patients and staff, we require this screening assessment to be completed on the day of your visit to our office in accordance with the Royal College of Dental Surgeons and Public Health Ontario. The well-being of everyone is our top priority and we appreciate your understanding during this time.
The questions on this form have been revised as of August 26, 2021 by the Ministry of Health - Ontario.

If you will be accompanying the patient, please complete a separate form for yourself and the patient.
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Patient/Person First Name *
Patient/Person Last Name *
Parent/Guardian Full Name ( if patient is under 16)
Preferred Contact Phone Number for TEXT and VOICE *
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