Patient Screening Form

Covid-19 Screening Form

Waterloo Emergency Dental Centre

258 King Street North, Unit #7,
Waterloo, Ontario, Canada N2J 2Y9
Phone: (519) 883-0505
Today's Date*
DD slash MM slash YYYY
Patient Name*
First Middle Last
Date of Birth*

Day
Month
Year
Who is Filling Out This Form?*
Please Specify
1. Are you fully vaccinated against COVID-19?*
If you are immunocompromised, select “No.”
- YES
- NO
2. In the last 14 days, have you been directed by a federal border agent to comply with federal quarantine requirements due to international travel?*
- YES
- NO
3. In the last 5 days (if fully vaccinated)/ 10 days (if unvaccinated or immunocompromised), have you experienced any of these symptoms?*
• Fever and/or chills
• Extreme tiredness
• Cough or barking cough
• Sore throat
• Shortness of breath
• Runny or stuffy/congested nose
• Decrease or loss of taste or smell
• Headache
• Muscle aches/joint pain
• Nausea, vomiting and/or diarrhea

Select “No” if all of these apply:
• You have completed your isolation period, or you tested negative for COVID-19 on one PCR test or rapid molecular test or two rapid antigen tests taken 24 to 48 hours apart, and
• You do not have a fever, and
• Your symptoms have been improving for 24 hours (48 hours if you have nausea, vomiting, and/or diarrhea)
- YES
- NO
4. Do any of the following apply?*
• You live with someone who is currently isolating because of a positive COVID-19 test
• You live with someone who is currently isolating because of COVID-19 symptoms
• You live with someone who is isolating while waiting for COVID-19 test results

Select “No” if you:
• are 18 or older and have received your booster dose, or
• are 17 or younger and are fully vaccinated, or
• completed your isolation after testing positive in the last 90 days (using a rapid antigen, rapid molecular, or PCR test)
- YES
- NO
5. In the last 5 days (if fully vaccinated)/ 10 days (if unvaccinated or immunocompromised), have you tested positive on a rapid antigen test, molecular test, or home-based self-testing kit?*
• You live with someone who is currently isolating because of a positive COVID-19 test
• You live with someone who is currently isolating because of COVID-19 symptoms
• You live with someone who is isolating while waiting for COVID-19 test results

Select “No” if you have already completed your isolation period because your symptoms started before your positive test result, and
• you do not have a fever, and
• your symptoms have been improving for 24 hours (48 hours if you have nausea, vomiting, and/or diarrhea
- YES
- NO
6. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?*
- YES
- NO
All the patients will be asked to sanitize their hands when arriving at the office.
Any “yes” response (other than Q1) must be discussed with the managing dentist immediately.
Patient Signature (Type Your Full Name)*
Date*
DD slash MM slash YYYY

Covid-19 Screening Form

Waterloo Emergency Dental Centre