Willowdale Dental Associates - Yonge & Sheppard
Patient Pre-Screening Form
25 Sheppard Ave. W., #125, North York, ON, M2N 6S6
416-226-2535
Full Name:
E-mail:
Yes
No
1) Are you immunocompromised and/or live in a highest-risk congregate care setting?
2) Do you have any of the following symptoms?
Yes
No
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
Yes
No
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
Yes
No
NA
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.
Signature
Clear
