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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
Patient First Name:
Patient Last Name:
Q1: Did you receive your final (or second) vaccination dose more than 14 days ago?
Q2: Do you have any of the following symptoms:
New onset of cough or worsening of chronic cough
Shortness of breath
Decrease or loss of sense of taste or smell
If adult > 18 years of age: unexplained fatigue/lethargy/malaise/muscle aches (myalgais)
If child < 18 years of age: nausea/vomiting, diarrhea
Q3: Have you tested positive for COVID 19 in the past 10 days or have you been told to isolate?
PLEASE NOTE: Questions 4 and 5 are to be answered only if you are NOT fully immunized.
Q4: Did you travel outside of Canada in the past 14 days?
Q5: Have you had close contact with a confirmed case of COVID 19 without wearing appropriate PPE?
SIGNATURE OF PATIENT
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