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. There are some new protocols when entering the office.
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 top priority and we appreciate your understanding during this time.
Patient First Name *
Patient Last Name *
Parent/Guardian Full Name ( if patient is under 16)
Preferred Contact Phone Number for TEXT and VOICE *
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