Willowdale Endodontics (Downtown Core)
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Patient Pre-Screening Form
181 University Ave, Ground Floor, Toronto, ON M5H 3M7
416-368-4500
Full Name:
E-mail:
Yes
No
Have you received your final (or second) vaccination dose more than 14 days ago?
*A fully immunized individual is defined as any individual >14 days after receiving their second dose of a two-dose COVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series (i.e. Johnson and Johnson).
In the past 14 days have you been directed by a federal border agent to comply with federal quarantine requirements due to international travel?
In the last 5 days have you experienced any of these symptoms?
Choose any/all that are new, worsening, and
not related to other known causes or conditions you already have.
Yes
No
Fever and/or chills
Cough or barking cough (croup)
Shortness of breath
Decrease or loss of taste or smell
Muscle aches/joint pain (Unusual, long-lasting)
Extreme tiredness (Unusual, fatigue, lack of energy)
Sore throat
Runny or stuffy/congested nose
Headache (New, unusual, long-lasting)
Nausea, vomiting and/or diarrhea
Yes
No
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
In the last 5 days, have you tested positive on a rapid antigen test, molecular test, or home-based self-testing kit?
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?
I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatment completed today during the COVID-19 pandemic.
Patient (Guardian) Signature
Clear
