Please enable JavaScript in your browser to complete this form.COVID-19 Patient Pre-ScreeningPatient Name *Date *Do you have a fever or have felt hot or feverish anytime in the last two weeks? *YesNoDo you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? *YesNoHave you experienced a recent loss of smell or taste? *YesNoHave you been in contact with anyone who has tested positive for COVID-19 or been asked to self- isolate by Public Health? *YesNoHave you returned from travel outside of Canada in the past 14 days? *YesNoHave you returned from travel within Canada from a location known affected with COVID-19? *YesNoAre you over the age of 60? *YesNoDo you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto- immune disorder? *YesNoI confirm that to my knowledge I am not currently positive for COVID-19 *YesNoPlease provide your contact information to help us better communicate with you during these times.Email Address *Cell # *I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatment completed during this COVID-19 pandemic.Patient Signature *Clear SignatureMessageSubmitCall or Email to book an appointment today! Our Services 416-299-1020 Appointment Booking Hours Mon: Closed Tues-Thurs: 10am – 7pm Fri-Sun: 9am – 5pm 1001 Sandhurst Circle, Unit 207 Scarborough, ON M1V1Z6 Book Appointment
