Viewmount Dental Centre

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? *

Email

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.

Do you have a fever or have felt hot or feverish anytime in the last two weeks? *

Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? *

Have you experienced a recent loss of smell or taste? *

Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19? *

Have you returned from travel outside of Canada in the last 14 days? *

Have you returned from travel within Canada from a location known affected with COVID-19? *

Are you over the age of 60? *

Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder? *

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.