Patient Screening Form

31 Kingsbury Dr Suite 110, Kitchener, ON N2A 2L9 519-896-7779

The information in this form is CONFIDENTIAL and enables our office to provide the highest level of care and service possible. Please complete all forms as completely as possible. Thank you.

Full Name:

E-mail:

	Yes	No
Q1: Are you immunocompromised and/or live in a highest-risk congregate care setting?
Q2: Do you have any of these symptoms? Choose any or all that are new, worsening and not related to other known causes or conditions. Fever and/or chills Cough or Barking Cough Shortness of breath Decrease or loss of sense of taste or smell Muscle aches/joint pain Extreme tiredness Sore throat Runny or stuffy nose Headache Nausea, vomiting and/or diarrhea Abdominal Pain Pink Eye
Q3: Have you been told (by a doctor, health care provider, public health unit, federal border agent, or other government authority) that you should currently be quarantining, isolating or staying at home?
Q4: In the last 10 days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self-testing kit?

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatment completed today.

Patient Screening Form

31 Kingsbury Dr Suite 110, Kitchener, ON N2A 2L9 519-896-7779

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