COVID Pre-Screening Form

Our COVID pre-screening form requires you to confirm each question. If there is an area you are unable to answer or have questions regarding the contents, please contact the office as soon as possible to review.

519-759-0011

  • Fever > 38
    Worsening chronic cough or new onset of cough
    Shortness of breath or difficulty breathing
    Difficulty swallowing or sore throat
    Decrease or loss of sense of taste or smell
    Unexplained fatigue/malaise/muscle aches
    Nausea/vomiting, diarrhea, abdominal pain
    Runny nose / nasal congestion
    Chills / Headaches / Pink eye
  • Date Format: MM slash DD slash YYYY
  • I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above-listed emergency or routine dental treatment completed during the COVID-19 pandemic.