Willowdale Dental Group - Yonge & Finch

Patient Pre-Screening Form

12 Finch Ave. West, Toronto, ON, M2N 6L1      416-221-9888

Full Name:
1) Are you immunocompromised and/or live in a highest-risk congregate care setting?
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
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?