COVID Pre-Screening – Bay Wellesley Dental

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About
- Our Practice
- Our Team
Promotions
Services
Patient Forms
FAQ
Blogs
Contacts

+1 647 370 5689

Appintment

COVID PRE-SCREENING

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COVID Pre-Screening Form

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

Full Name *

Email Address *

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?

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 *

Do you have any of the following symptoms? (copy)

Delirium *

Unexplained or increased number of falls *

Acute functional decline *

Worsening of chronic conditions *

Agree *

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.

Signature

[current_date]

Contact Us

+1 647 370 5689

office@baywellesleydental.com
app@baywellesleydental.com

15 Wellesley St W., Unit 210
Toronto, ON, M4Y 0G7

Fax: 416.920.6777

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Office Hours

Monday // 10 AM – 7 PM
Tuesday // 10 AM – 7 PM
Wednesday // 10 AM – 7 PM
Thursday // 10 AM – 7 PM
Friday // 10 AM – 7 PM
Saturday // 10 AM – 6 PM
Sunday // Closed

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