1.866.486.4876
info@yorkmillsortho.ca
Friend Referral
Dental Referral
COVID-19 UPDATE CLICK HERE
Leave Us A Google Review
Orthodontist North York | Braces North York | Invisalign North York
Toggle menu
Skip to content
Home
About Us
Our Policies + Mission
Meet Dr. Morrow
Meet Dr. Haiat
Meet Our Staff
Our Office
Flexible Payment Plans
Patient Rewards
Patient Testimonials
Before & After Smiles
Blog
New Patients
First Visit
Patient Forms
Oral Hygiene
Common Problems
Emergency Info
FAQ
Glossary
Related Links
Kid’s Korner
Treatment
Early Treatment
Adult Treatment
Types of Braces
Invisalign
Invisalign FAQ
Retention
Orthognathic Surgery
Acceledent
iTero Scanner
Temporary Anchorage Devices
Soft-Tissue Laser Treatment
PROPEL ORTHODONTICS
Palatal Expanders
Lightforce
Cost Calculator
Patient Login
Referral
Friend Referral
Dental Referral
Contact
Sponsorship Request
covid-19 screening form
Thank you for scheduling your appointment with York Mills Orthodontics. We look forward to seeing you!
In order for us to see you in our office, you are required to complete this form no sooner than the morning of your appointment.
Please carefully review the questionnaire below and answer each question accurately. Once completed, please sign at the bottom and push SUBMIT. Thank you for helping us to ensure the health and safety of our patients, staff and the community.
COVID-19 Pandemic Dental Treatment Consent Form
Q1: Are you immuno-compromised?
Yes
No
Q2: Do you have any of these symptoms? Are these symptoms new, worsening and not related to other known causes of conditions
2
?
Yes
No
Fever and/or chills
Cough or barking cough
Shortness of breath
Decrease or loss of taste or smell
Muscle aches/joint pain
Extreme tiredness
Sore throat
Runny or stuffy/congested nose
Headache
Nausea, vomiting and/or diarrhea
Abdominal pain
Pink eye
Q3: Have you been told (by a doctor, health care provider, public health unite, federal border agent, or other government authority) that you should currently be a 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
PLEASE NOTE:
If you answered "yes" to any question above, please speak to our front desk.
SIGNATURE OF PATIENT
Printed Name
Date
(YYYY-MM-DD)
Search
+
ARE YOU READY TO DISCUSS YOUR NEW SMILE? CALL
1.866.486.4876
START YOUR VIRTUAL CONSULT >
×