Covid-19 Screening Form

First Name : *

Last Name : *

Email :

Phone Number : *

Have you been to Findlay Creek Family Dental before? *

Yes No

I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. *

Agree

I understand that dental procedures create water spray which is one way that the novel coronavirus can spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus. *

Agree

Are you presenting any of the following symptoms of COVID-19 identified by Public Health Services?

Fever > 38°C *

Yes No

Cough (new or worsening chronic) *

Yes No

Sore Throat *

Yes No

Shortness of Breath *

Yes No

Difficulty Breathing *

Yes No

Flu-like symptoms *

Yes No

Nausea / vomiting, diarrhea, abdominal cramps (or unknown origin) *

Yes No

Conjunctivitis (Pink Eye) *

Yes No

Decrease of loss of sense of taste or smell *

Yes No

Chills *

Yes No

Headaches *

Yes No

Unexplained Fatigue / Malaise / Muscle Aches *

Yes No

Runny nose / nasal congestion without other known cause *

Yes No

Have you tested positive for COVID-19 OR had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? *

Yes No

Are you waiting for the results of a laboratory test for the novel coronavirus? *

Yes No

Have you returned to Ontario from any country outside of Canada whether by car, air, bus or train in the past 14 days? *

Yes No

Have you been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by Public Health, the Communicable Disease Control or any other governmental health agency? *

Yes No

I understand that any travel from any country outside of Canada, including travel by car, air, bus or train, significantly increases my risk of contracting and transmitting the novel coronavirus. Public Health requires self-isolation for 14 days from the date a person has returned to Canada. *

Yes No

I understand that Public Health has asked individuals to maintain physical distancing of at least 2 meters (6 feet) and it is not possible to maintain this distance and receive dental treatment. *

Yes No

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above listed dental treatment completed during the COVID-19 pandemic *

Yes No

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Our
Contact

Address
4100 Albion Rd S, Gloucester, ON K1T 3W1

Phone
613-822-1500

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Hours Of
Operation

Monday to Friday
9am to 5pm

Saturday & Sunday
By Appointment