Trafalgar Village Dental
Patient Screening Form
117 Cross Avenue, Oakville, ON L6J 2W7
Temperature Check In Office - ℃
Did you receive your final (or second) vaccination dose more than 14 days ago?
fully immunized please answer Q4 and Q5 as well.
Do you have any of the following symptons:
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?
Did you travel outside of Canada in the past 14 days?
Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
I verify all of this information to be accurate and true.
Online Patient Forms