COVID-19 Screening Form - Haysboro Dental Care

Patient Name *

Phone *

Email *

Do you have a fever or have felt hot or feverish anytime in the last 10 days? *

Yes
No

Do you have any of these symptoms: *

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

Yes
No

Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19? (Healthcare workers who have worn appropriate PPE may answer No) *

Yes
No

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

Yes
No

Is your workplace considered high risk?(Healthcare workers who have worn appropriate PPE may answer No) *

Yes
No

Are you over the age of 65? *

Yes
No

Do you have any of the following? *

Signature *

I agree that my typed name below will be as valid as a handwritten signature to the extent allowed by local law

LEGAL NAME *