COVID MED HX QUESTIONS | DrsEcklerBlack&Leung

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WE ARE ASKING ALL PATIENTS TO FILL IN AND SUBMIT THE BELOW QUESITONS BEFORE COMING TO THEIR APPOINTMENT. WE ALSO ASK THAT IF THE PATIENT NEEDS TO BE ACCOMPANIED PLEASE HAVE THE ACCOMPANYING PERSON FILL IN THE FORM AS WELL.

Patient Pre-Screening Questionnaire

Please check the boxes which apply to you

Does patient have fever or have you/they felt hot or feverish recently (the last 14 days)?

Does the patient have shortness of breath or other difficulties breathing?

Does the patient currently have a cough?

Does the patient have any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Has the patient experienced recent loss of taste or smell?

Has the patient been in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Has the patient traveled in the past 14 days?

None of the above apply to me

Your Signature

Guardians Signature

As of Sunday, March 15th, 2020 at 5:30 PM, the Royal College of Dental Surgeons of Ontario has mandated that ALL dental practitioners stop providing non-emergency dental care. This means that we are not allowed to treat patients except in the case of an emergency.

Orthodontic emergencies could include painful or pokey wires and/or loose appliances.

**Loose brackets, regular appointments and/or routine visits are not considered dental emergencies so once we are back to regular operating hours, we will take care of all your concerns then.

Please select your emergency from the drop down menu below.

Please upload a picture of your concern

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I hereby declare that the above information is true and to the best of my knowledge

Thank you!

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