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COVID-19 Screening Form

Please fill out the mandated COVID-19 Screening Form below before your next appointment.

COVID-19 Screening FORM

Are you a current or new patient?*
Patient Name*
MM slash DD slash YYYY
Time
:
Question 1: Did you receive your final (or second) vaccination dose more than 14 days ago?
Ques 1
* A fully immunized individual is defined as any individual >14 days after receiving their second dose of a two-dose COVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series (i.e .Johnson and Johnson).
Question 2: Do you have any of the following symptoms?
Ques 2
Question 3: Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating?
Ques 3
Question 4: Have you travelled outside of Canada in the past 14 days?
Ques 4
Question 5: Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
Ques 5
MM slash DD slash YYYY

New Patient Form

UPDATED MEDICAL HISTORY

PATIENT CONSENT FORM

CHILDREN’S PATIENT FORM

Patients Name*
MM slash DD slash YYYY
Address*
MM slash DD slash YYYY
Parent / Guardian Name*
Please check any of the following that apply:
Has the child ever had any of the following?*

Does your child have or have they ever had any of the following?

Please check any of the following that apply:*

For Parents

Dental Insurance

Parent Name (required for under 18 years)*
Use your mouse or finger to draw your signature above

DENTIST REFERRAL