Website URL*Patient Name :Date of Appointment :1. Did you/the patient have close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days?YESNO2. Do you/the patient have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID -19?YESNO3. Do you/the patient have any of the following symptoms: (please circle if any are YES)-fever-difficulty breathing-shortness of breath-new onset of cough-worsening chronic cough-sore throat-difficulty swallowing-chills-decrease or loss of sense of taste or smell-unexplained fatigue/malaise/muscle aches (myalgias)-nausea/vomiting, diarrhea, abdominal pain -runny nose/nasal congestion without other known cause-headaches-pink eye (conjunctivitis)4. If you/the patient is over 70 years of age or older, and experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?5. TEMPERATURE READINGI have answered truthfully and consent to continue care in the dental office today. Send
