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HOME
PATIENT CENTRE
Patient Forms
New Patient Form
Medical History Update
5-Year Medical History Update
Covid-19 Patient Screening Form
COVID-19 Pandemic Dental Risk Consent
SERVICES
Emergency Services
Emergency Dental Exams
Dental X-Rays
Cuts & Lacerations
Dental Root Canal
Dental Filling Cavities
Crowns & Bridges
Repair Broken Teeth, Fillings, Crowns & Dentures
Replacement Of Fillings & Crowns
Removal Of Foreign Bodies
Treatment Complications
Cleaning and Prevention
Complicated Tooth Extractions
Dental Restorations
Cosmetic Dentistry
Periodontal Disease
FOR STUDENTS
BLOG
News
SERVICE AREAS
Waterloo
Beechwood Waterloo Ontario
Beechwood West-Ontario
Clair Hills-Ontario
Colonial Acres-Ontario
Upper Beechwood-Ontario
View All Areas
Book An Appointment
Covid-19 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?
*
Patient
Other
Please Specify
Q1. Are you immunocompromised?
*
Factors such as old age, diabetes and end-stage renal disease are generally not considered immunocompromised. Examples of being immunocompromised include individuals: • undergoing cancer chemotherapy • with untreated HIV infection with CD4 T lymphocyte count less than 200 • with combined primary immunodeficiency disorder • on prednisone medication - more than 20 mg per day (or equivalent) for more than 14 days • on other immune suppressive medications.
YES
NO
Q2: Do you have any of these symptoms? Choose any or all that are new, worsening and not related to other known causes or conditions
*
• 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 • Abdominal pain • Pink eye
Select “No” if all of these apply: • 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
Q3: Have you been told (by a doctor, health care provider, public health unit, federal border agent, or other government authority) that you should currently be quarantining, isolating or staying at home?
*
YES
NO
Q4: In the last 10 days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self-testing kit?
*
YES
NO
Any “yes” response (other than Q1) must be discussed with the managing dentist immediately. When you arrive at the office, you will be asked to sanitize your hands.
Patient Signature (Type Your Full Name)
*
Date
*
DD slash MM slash YYYY
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