Harbourfront Dental

Patient Pre-Screening Form

10 Lower Spadina Avenue, Suite 202, Toronto, ON, M5V 2Z2      416-260-2001

Full Name:
E-mail:
YesNo
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?YesNo
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
YesNo
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 1YesNoNA
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?

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