COVID-19 Patient Pre-Screening Questionnaire
In order to safe-guard our dental office, and the rest of our community, we ask that you complete this form prior to arriving at our office. If you are experiencing any COVID-19 symptoms, we politely ask that you do not come to our office at this time.
Sign in to Google to save your progress. Learn more
Email *
Patient Name *
I understand that COVID-19 has a long incubation period, during which carriers of the virus may not show symptoms and still be contagious. *
Do you have a fever, or have you been feverish at any point in the last 10 days? *
Do you have any  of the following symptoms: New or worsening cough? New or worsening shortness of breath? Headache? Sore throat? Runny nose? New loss of taste and/or smell? *
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 for travel outside of Canada in the last 14 days? *
Have you returned from travel within Canada from a location known to be affected with COVID-19 in the last 14 days? *
Is your work place considered high risk? *
Are you over the age of 65 and/or have pre-existing health conditions related to the following: Heart disease, lung disease, diabetes, chronic kidney or liver disease, or immunocompromised? *
Have you attened any large group functions in the last 14 days? [ Functions over 10 people] *
Patient Electronic Signature *
Clear selection
A copy of your responses will be emailed to the address you provided.
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy