Back to all forms

Patient Pre Screening Form

Pre screening before your appointment and then again when you arrive for your appointment.

Name:(Required)
Do you have a fever or have felt hot or feverish anytime in the last 2 weeks?(Required)
Do you have any of these symptoms: Dry cough? Shortness of Breath? Difficulty breathing? Sore throat? Runny nose?(Required)
Have you experienced a recent loss of smell or taste?(Required)
Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?(Required)
Have you returned from travel outside of Canada in the last 14 days?(Required)
Have you returned from travel within Canada from a location known affected with COVID-19?(Required)
Are you over the age of 60?(Required)
Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?(Required)
Do you have pink eye?(Required)
Do you have redness of the eye?(Required)
Are you Vaccinated? (If 'NO', see last question***)(Required)
Have you received your second vaccination dose more than 14 days ago?(Required)
Have you tested positive for COVID-19 in the past 10 days or have been self isolating?(Required)
***If not fully vaccinated, 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 essential treatment/surgical/dental treatment completed during the COVID-19 pandemic.
MM slash DD slash YYYY
Your signature lets us know that you have read and acknowledge the attached below changes in our office. Please ensure that you have fully understood in advance so you are ready prior to your appointment. We need to ensure we are taking ALL proper precautions at all times. You will be pre-screened again prior to entering the office as well.
Thank you.