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Search for:
Home
About Us
Why Us
Parent FAQs
Services
Dental Implants
Dental Fillings
Dental Braces
Wisdom Tooth Extraction
Teeth Whitening
Dental Emergency
Invisalign
Dental Veneers
Root Canal Treatment
Dental Crowns & Bridges
Dentures
Children Dentistry
Sleep Apnea
Periodontal Treatments
Gallery
Dental Cases
Dental Videos
Blog
Contact
Make An Appointment
Covid 19 Screening Form
Home
About Us
Why Us
Parent FAQs
Services
Dental Implants
Dental Fillings
Dental Braces
Wisdom Tooth Extraction
Teeth Whitening
Dental Emergency
Invisalign
Dental Veneers
Root Canal Treatment
Dental Crowns & Bridges
Dentures
Children Dentistry
Sleep Apnea
Periodontal Treatments
Gallery
Dental Cases
Dental Videos
Blog
Contact
Make An Appointment
Covid 19 Screening Form
COVID-19 Patient Screening Form
COVID-19 Patient Screening Form
Sunrise Dentistry
2020-07-21T07:05:05-04:00
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Do you have a concern for a potential COVID-19 infection for the person?
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Did the person have close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days?
Yes
No
Does the person have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?
Yes
No
Does the person have any of the following symptoms:
Fever
New onset of cough
Worsening chronic cough
Shortness of breath
Difficulty breathing
Sore throat
Difficulty swallowing
Decrease or loss of sense of taste or smell
Chills
Headaches
Unexplained fatigue/malaise/muscle aches (myalgias)
Nausea/vomiting, diarrhea, abdominal pain
Pink eye (conjunctivitis)
Runny nose/nasal congestion without other known cause
None of the above
If the person is 70 years of age or older, are they experiencing any of the following symptoms:
Delirium
Unexplained or increased number of falls
Acute functional decline
Worsening of chronic conditions
None of the above
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