Patient Pre-Screening Form
10 Lower Spadina Avenue, Suite 202, Toronto, ON, M5V 2Z2
1) Have you received your final (or second) vaccination dose more than 14 days ago?
*A fully immunized individual is defined as any individual >14 days after receiving their second dose of a two-dose COVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series (i.e. Johnson and Johnson).
2) Do you have any of the following symptoms?
Fever and/or chills
New onset of cough or worsening chronic cough
Shortness of breath
Decrease or lost sense of taste or smell
If adult > 18 years of age: Unexplained fatigue/lethargy/malaise/muscle aches
If child < 18 years of age: nausea/vomiting, diarrhea
3) Have you tested positive for COVID-19 in the past 10 days or have you been told to isolate?
The following questions are applicable if you answered “NO” to question 1
4) Have you traveled outside of Canada in the past 14 days?
5) Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
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 during the COVID-19 pandemic.
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