Downtown Whitby Dentistry

Patient Screening Form

130 Byron Street North, Whitby, ON, L1N 4M9      905-430-7045

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?
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 14 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 or anyone under isolation in the last 14 days?

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