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Emergency Services
1360 Kingston Rd #12,
Pickering,
ON
L1V 3B4
CA
(905) 839-4427
Request Appointment
New Patients Welcome!
Home
About Us
Our Practice
Our Team
Dental Technology
Safety Protocols
Services
General Dentistry
Dental Hygiene
Cosmetic Services
Children's Services
Oral Surgery
Orthodontics
Dental Appliances
Dental Sedation
Emergencies
Contact
Review Us
COVID-19 Patient Screening
Please answer the following questions to ensure you are COVID-19 symptom free.
Patient Name
*
1. Have you tested positive for COVID-19 in the past 14 days?
*
Yes
No
2. Have you been in contact with anyone with confirmed COVID-19 in the past 14 days AND been advised to self-isolate?
*
Yes
No
3. Do you have, or have you had within the past 14 days, any of the following symptoms:
Fever above (38 degrees celsius) or feeling hot, chills/feverish
*
Yes
No
Shortness of breath or other difficulties breathing
*
Yes
No
Cough or worsening of a chronic cough
*
Yes
No
Flu-like symptoms such as stomach upset, diarrhea, headache, fatigue or sore throat
*
Yes
No
Recent alteration or loss of taste or smell
*
Yes
No
Any new, unusual symptoms, e.g., feeling unwell, or sudden onset of runny nose
*
Yes
No
4. Have you been in contact with anyone with any of the above symptoms of possible COVID-19 in the past 14 days AND been advised to self-isolate?
*
Yes
No
5. If you have conditions or comorbidities that may make you more vulnerable to COVID-19 that you would like to share, please do so here:
6. Have you traveled in the past 14 days outside of the province and/or country AND been advised to self-isolate?
*
Yes
No
"YES" responses to any of these questions would indicate the need for a deeper discussion with the dentist before proceeding with treatment.
7. Are you fully vaccinated against COVID-19? Fully vaccinated means that it has been at least 14 days since you received the second dose of the Pfizer, Moderna, or AstraZeneca COVID-19 vaccine or the Janssen COVID-19 vaccine.
Yes
No
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(905) 839-4427
