COVID 19 SCREENING FORM

COVID-19 Screening Form

AS PER THE ROYAL COLLEGE OF DENTAL SURGEONS OF ONTARIO, ALL PATIENTS ARE REQUIRED TO BE SCREENED BOTH BEFORE THEIR APPOINTMENT AND UPON ARRIVAL OF THEIR APPOINTMENT.

Any "yes" response must be discussed with our office immediately.

Once you arrive for your appointment, you will be required to:

Sanitize your hands
Answer the questions again

Have your temperature taken

Complete a form acknowledging the risks of COVID-19

Please call us from your vehicle/parking lot when you arrive. Also, only patients will be allowed to come into the office.

COVID-19 Pre-Screening Form

PLEASE NOTE: If You Have Multiple Children Booked For An Appointment, You Will Need To Fill Out A New Form For Each Child.

Simply Refresh Your Browser After Filling Out The 1st Form And A New Form Will Generate.

Contact Us

New Field:

Who Is Filling Out This Form?

Phone Number:

Email:

I Prefer To Be Contacted By:

SCREENING QUESTIONS: Have You Travelled Outside Of Canada In The Past 14 Days?

Have You Tested Positive For COVID-19 Or Had Close Contact With A Confirmed Case Of COVID-19 Without Wearing Appropriate PPE?

Do You Have Any Of The Following Symptoms: Fever, New Onset Of Cough, Shortness Of Breath, Difficulty Breathing, Sore Throat, Difficulty Swallowing, Decrease Or Loss Of Sense Of Taste Or Smell, Chills, Headaches, Unexplained Fatigue, Malaise, And/Or Muscle Aches, Nausea And/Or Vomiting, Diarrhea And/Or Abdominal Pain, Pink Eye, Runny Nose Or Nasal Congestion Without Another Known Cause?

If You Are 70 Years Of Age Or Older, Have You Experienced Any Of The Following Symptoms: Delirium, Unexplained Or Increased Number Of Falls, Acute Functional Decline Or Worsening Of Chronic Conditions ?

Contact Us

(905) 503-5300
i nfo@kidsworlddentistry.com
222 Wellington St. E, Suite 200

Aurora, ON L4G 1J5

Website Built By The Awesome People At Flowerpot Marketing

COVID-19 Screening Form

COVID-19 Pre-Screening Form

Contact Us

Contact Us

(905) 503-5300info@kidsworlddentistry.com222 Wellington St. E, Suite 200

Aurora, ON L4G 1J5

Website Built By The Awesome People At Flowerpot Marketing﻿

(905) 503-5300
i nfo@kidsworlddentistry.com
222 Wellington St. E, Suite 200

Website Built By The Awesome People At Flowerpot Marketing