Copper Creek Dental
Patient Screening Form
501-560 Copper Creek Drive, Markham, Ontario, L6B 0S1
905-294-0688
Patient Name:
Patient Age:
E-mail:
Date
Temperature Check In Office - ℃
Screening Questions
Pre-Screen
In-Office
Yes
No
Yes
No
Q1:
Are you fully vaccinated against COVID-19 and/or aged 11 or younger?
Q2:
In the last 14 days, have you travelled outside of Canada and NOT been exempt from federal quarantine requirements?
Q3:
In the last 5 days (if fully vaccinated)/ 10 days (if unvaccinated or immunocompromised), have you experienced any of theses symptoms:
Fever and/or chills
Cough or Barking Cough
Shortness of breath
Decrease or loss of sense of taste or smell
Muscle aches/joint pain
Extreme tiredness
Sore throat
Headache
Nausea, vomiting and/or diarrhea
Q4:
Do any of the following apply?
You live with someone who is currently isolating because of a positive COVID-19 test
You live with someone who is currently isolating because of COVID-19 symptoms
You live with someone who is isolating while waiting for COVID-19 test resu
Q5:
In the last 5 days (if fully vaccinated)/ 10 days (if unvaccinated or immunocompromised), have you tested positive on a rapid antigen test, molecular test, or home-based self-testing kit?
Q6:
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?
I verify all of this information to be accurate and true.
Signature
Clear
