COVID-19 Pre-Appointment Screening Form Patient Name* First Last Email* Date of Birth:* Month Day Year Has there been any change to your contact information?* Yes No Please provide the updated contact information:*Has there been any change to your health, including changes in medications?* Yes No We request patients come to their appointment alone wherever possible. We do make exceptions for parents/guardians, caretakers or translators if absolutely necessary. Will you be coming alone to your appointment?* Yes No ***If someone will be attending the appointment, be sure to complete a pre-screening for them as well Do you have a confirmed case of COVID-19 or have you had close contact with a confirmed case of COVID-19?* Yes No Have you been in contact with any person self-isolating because of a determined risk for COVID-19?* Yes No Have you had close contact with anyone with acute respiratory illness in the past 14 days?* Yes No Have you returned from travel outside of Ontario in the last 14 days?* Yes No Do you have a fever (above 38C) or have felt hot or feverish anytime in the last two weeks?* Yes No Do you have any of these symptoms:* New onset of cough or worsening chronic cough Shortness of breath Difficulty breathing Sore throat Difficulty swallowing Chills Headaches Unexplained fatigue/malaise/muscle aches Nausea/vomiting, diarrhea, abdominal pain Pink eye (conjunctivitis) Runny nose or nasal congestion without other known cause None of the above Have you experienced a recent loss of smell or taste?* Yes No Are you over the age of 60?* Yes No Have you experienced any of the following symptoms:* Delirium Unexplained or increased number of falls Acute functional decline Worsening of chronic conditions None of the above Do you have any of the following: Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?* Yes No * I verify that the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have my dental treatment completed during the COVID-19 pandemic.