Stonehaven Dentistry

Patient Screening Form

7470 Airport Rd., Unit 2, Mississauga, ON, L4T 2H5      905-364-0077

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:
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?