Baywellesley Dental

COVID Pre-Screening

COVID Pre-Screening Form

Note: information marked with star (*) are mandatory and must be filled out.

Full Name : *

Email Address : *

	Yes	No
Have you had close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days? *
Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19? *

Do you have any of the following symptoms?

	Yes	No
Fever *
New Onset of Cough *
Worsening Chronic Cough *
Shortness of Breath *
Difficulty Breathing *
Sore throat *
Difficulty Swallowing *
Decrease or loss of sense of taste of smell *
Chills *
Headaches *
Unexplained fatigue/malaise/muscle aches (myalgias) *
Nausea/vomiting, diarrhea, abdominal cramps (of unknown origin) *
Pink eye (conjunctivitis) *
Runny nose/nasal congestion without other known cause *

If you are over the age of 70, are you experiencing any of the following symptoms:

	Yes	No	N/A
Delirium *
Unexplained or increased number of falls *
Acute functional decline *
Worsening of chronic conditions *

I verify the information provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatment completed today during the COVID-19 pandemic. *

Date:

Patient (Guardian) Signature *