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COVID-19 Patient Screening Form

Prior to all dental visits, patients are encouraged to complete the COVID-19 screening form prior to all dental visits. These questions will be asked again when the patient arrives at the office for their scheduled appointment.  

  • Only patients should be entering the office unless a parent or support person is needed.
  • To help with social distancing, patients should wait in their car until 5 minutes before the scheduled appointment time then you may enter the office.
  • Upon arrival at the office, all patients will be asked to:
    • Wear a mask until seated in a dental chair.
    • Sanitize hands with the provided hand sanitizer.
    • Answer the screening questions.
1. Have you received your final (or second) COVID-19 vaccination dose more than 14 days ago? * A fully immunized individual is defined as any individual >14 days after receiving their second dose of a 2-dose COVID-19 series or their first dose of a one-dose COVID-19 Vaccine. ie. Johnson & Johnson.
3. Do you or anyone you live with have concerns for a potential COVID-19 exposure or awaiting COVID-19 test results?
4. Have you tested positive for COVID-19 in the past 10 days or been told you should be isolating?
ATTENTION: If you answered "No" or "Prefer Not to Say" for Question 1, please answer questions 5 and 6 to complete your screening.
5. Have you traveled outside of Canada in the past 14 days?
6. Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?