COVID-19 Patient Screening Form - TechTown Dentistry

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COVID-19 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 reviewed when you arrive at the office for the scheduled appointment.

Only patients should enter 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.
Mask wear is optional and at the discretion of the patient. Our staff will continue to be masked during your visit.
Sanitize hands with the provided hand sanitizer.

* Patient Name

* Patient Age

* Date/Time of Dental Visit:

1. Are you immunocompromised?

* Immune Status

Yes No

2. Do you have any of these symptoms? Select any that are new, worsening, and not related to other known causes or conditions. (please check)

Fever and/or chills New onset of cough or worsening of chronic cough Shortness of breath or difficulty breathing Decrease or loss of smell or taste Unexplained fatigue / muscle aches Nausea, vomiting, diarrhea, abdominal pain Runny or stuffy/congested nose Sore throat Pink eye Headache

3. Have you been told (by a doctor, healthcare provider, public health unit or government authority) that you should be quarantining, isolating or staying at home?

* Quarantine status

Yes No

4. In the last 10 days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid antigen test or self-testing kit?

* Positive test results

Yes No

Signature of Patient/Guardian (to be signed in-office):

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ADDRESS:
180 Northfield Dr. West
Waterloo, ON N2L 0C7

Phone: (519)-746-7333

Email: [email protected]