Viewmount Dental Centre

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COVID-19 Screening Form for current patients

Please only use this form if you are a current patients, new patients need to use our New Patient Form.

Welcome to Our Office. Your overall health is important to us. We strive to treat all patients in a safe and effective manner and need to ask some detailed questions related to your general

Private & Confidential Health History and Personal Information

Name *

First

Last

Phone *

Best email to contact you? *

Confirm Email

Date of Birth *

COVID-19 Screening Question

We are required by our Regulating body to screen you for COVID-19. Please answer the following to the best of your knowledge.

Q1: Did you receive your final (or second) vaccination dose more than 14 days ago? *

Q2: Does you have any of the following symptoms?

Fever and/or chills? *

New onset of cough or worsening chronic cough ?) *

Shortness of breath ? *

Decrease or loss of sense of taste or smell? *

If adult >18 years of age: unexplained fatigue/lethargy malaise muscle aches(myalgias)? *

If child <18 years of age: nausea/ vomiting, diarrhea? *

Q3: Have you tested positive for COVID-19 in the past 10 days or have they been told they should be isolating? *

Q4: Did you travel outside of Canada in the past 14 days? *

Q5: Have you been in close contact with a confirmed case of COVID-19 without wearing appropriate PPE? *

Are you over the age of 60? *

Do you have a concern for a potential COVID-19 infection for you (e.g. is there an outbreak in the facility, that a is patient awaiting COVID-19 test results, etc)? *

This is the last section. Note that you will not be able to go back after clicking [Next]. Please ensure that the information you provided is accurate to the best of your knowledge.

To comply with Canada's anti-spam law, we want to confirm that you would like to contine receiving our emails. We mostly use email to send our appointment reminders and reply to patients' request to change or book appointments. Please select (Yes or No) *

More information about the regulations can be found at:
https://www.fightspam.gc.ca/eic/site/030.nsf/eng/home

Please click Submit to send us your information

Thank you for taking the time to complete this form prior to your appointment. The welfare of our patients and our staff is of the utmost importance to us your cooperation is helping us address the health needs during these challenging times.