Screening Form - Dentistry On Brant

COVID-19 Patient Screening Form

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Patient Name:

Appointment date:

DD MM YYYY

Have you had close contact with anyone with acute respiratory illness or travelled outside of Ontario in the last 14 days?

Yes

Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?

Yes

Do you have any of the following symptoms: • Fever • New onset of cough • Worsening chronic cough • Shortness of breath • Difficulty breathing • Sore throat • Difficulty swallowing • Decrease or loss of sense of taste or smell • Chill • Headaches • Unexplained fatigue/malaise/muscle aches (myalgia’s) • Nausea/vomiting, diarrhea, abdominal pain Pink eye (conjunctivitis) • Runny nose/nasal congestion without other known cause

Yes

Are you 70 years of age or older, experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?

Yes

When you arrive to the office you will be asked to:

Remain in your car and call the office at 905 633 7373. A member of our team will let you know when we are ready for you
Patients should come alone to their appointment unless you are a parent to a young child, or a caregiver/support worker. (In this case, you must be screened as well)
Wear a mask to your appointment
Sanitize their hands