Trafalgar Village Dental

Patient Screening Form

117 Cross Avenue, Oakville, ON L6J 2W7      905-339-0404

Patient Name:
Patient Age:
E-mail:
Date
Temperature Check In Office - ℃
Screening QuestionsPre-ScreenIn-Office
YesNoYesNo
Q1: Did you receive your final (or second) vaccination dose more than 14 days ago?

If NOT fully immunized please answer Q4 and Q5 as well.
Q2: Do you have any of the following symptons:
  • Fever
  • New Onset of Cough or worsening chronic cough
  • Shortness of breath
  • Decrease or loss of sense of taste or smell
  • If adult > 18 years of age: unexplained fatigue/lethargy/malaise/muscle aches (myalgias)
  • If child < 18 years of age: nausea/vomiting, diarrhea
Have you tested positive for COVID-19 in the past 10 days or have you been told to isolate?
Q4: Did you travel outside of Canada in the past 14 days?
Q5: Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

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