Patient Screening Form - Shiff Family Dentistry

Today's Date

Patient Name*

First Last

Phone*

Patient Age*

Screening Questions:

Have you tested positive for COVID-19 in the past 10 days or have you been asked to isolate?*

Do you have any of the following symptoms

Fever
Chills
Shortness of breath
Decrease or loss of taste/ smell
If an adult (over age of 15) unexplained fatigue/ lethargy/ malaise/ muscle aches (myalgias)
If a child (under age of 18) nausea/ vomiting/ diarrhea

Check all that apply to you.

Have you received your final dose of the COVID-19 vaccine at least 14 days ago?*

Have you traveled outside Canada in the past 14 days?*

Have you been in close contact with a confirmed case of COVID-19 without wearing appropriate PPE?*

Consent*

I willingly agree to receive treatment with the Shiff Family Dentistry team. I have answered the above questions to the best of my knowledge.