Pre-Treatment Screening Form

Do you/they have fever or have you/they felt hot or feverish recently
(14-21 days)?

Yes No

Are you/they having shortness of breath or other difficulties breathing?

Yes No

Do you/they have a cough?

Yes No

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Yes No

Have you/they experienced recent loss of taste or smell?

Yes No

Are you/they in contact with any confirmed COVID-19 positive patients?
Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Yes No

Is your age over 60?

Yes No

Do you/they have heart disease, lung disease, kidney disease,
diabetes or any auto-immune disorders?

Yes No

Have you/they traveled in the past 14 days to any regions affected
by COVID-19? (as relevant to your location)

Yes No

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.

COVID-19 Screening Form

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?

Are you/they having shortness of breath or other difficulties breathing?

Do you/they have a cough?

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Have you/they experienced recent loss of taste or smell?

Are you/they in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Is your age over 60?

Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

Do you/they have fever or have you/they felt hot or feverish recently
(14-21 days)?

Are you/they in contact with any confirmed COVID-19 positive patients?
Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Do you/they have heart disease, lung disease, kidney disease,
diabetes or any auto-immune disorders?

Have you/they traveled in the past 14 days to any regions affected
by COVID-19? (as relevant to your location)