Downtown Dental Associates
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Patient Pre-Screening Form
181 University Ave., Toronto, ON, M5H 3M7
416-368-4500
Full Name:
E-mail:
Yes
No
1) Are you immunocompromised and/or live in a highest-risk congregate care setting?
2) Do you have any of the following symptoms?
Yes
No
Fever and/or chills
New onset of cough or worsening chronic cough
Shortness of breath
Decrease or lost sense of taste or smell
If adult > 18 years of age: Unexplained fatigue/lethargy/malaise/muscle aches
If child < 18 years of age: nausea/vomiting, diarrhea
Yes
No
3) Have you tested positive for COVID-19 in the past 10 days or have you been told to isolate?
The following questions are applicable if you answered “NO” to question 1
Yes
No
NA
4) Have you traveled outside of Canada in the past 14 days?
5) 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 have dental treatment completed today during the COVID-19 pandemic.
Patient (Guardian) Signature
Clear
