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COVID-19 PRESCREENING FORM

City Heights Dental Centre In Mississauga -

Pre-Screening Form

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BOOK APPOINTMENT ONLINE

City Heights Dental

Appointment Pre-Screening Form

Please be advised this form MUST be completed before we can begin your appointment (either online or in-person).

Any "yes" response must be discussed with our office immediately.

Once you arrive for your appointment, you will be required to:

Sanitize your hands
Answer the questions again

Have your temperature taken

Complete a form acknowledging the risks of COVID-19

Contact Us

Patient Full Name:

Patient Age:

Who Is Filling Out This Form:

Phone:

Email:

I Prefer To Be Contacted By:

Have You Tested Positive For COVID-19 Or Had Close Contact With A Confirmed Case Of COVID-19 Without Wearing Appropriate PPE?

Have You Travelled Outside Of Canada In The Past 14 Days?

Do You Have Any Of The Following Symptoms:

Fever

Yes

No

Chills

Yes

No

Pink Eye

Yes

No

New Onset Of Cough

Yes

No

Shortness Of Breath and/or Difficulty Breathing

Yes

No

Decrease Or Loss Of Sense Of Taste Or Smell

Yes

No

Sore Throat

Yes

No

Difficulty Swallowing

Yes

No

Decrease Or Loss Of Sense Of Taste Or Smell

Yes

No

Headaches

Yes

No

Nausea and/or Vomiting

Yes

No

Worsening Of Chronic Cough

Yes

No

Diarrhea and/or Abdominal Pain

Yes

No

Unexplained Fatigue, Malaise, and/or Muscle Aches

Yes

No

Runny Nose Or Nasal Congestion Without another Known Cause

Yes

No

(If 70 Years Of Age Or Older) Have You Experienced Any Of The Following Symptoms:

Delirium

Yes

No

N/A

Unexplained Or Increased Number Of Falls

Yes

No

N/A

Acute Functional Decline

Yes

No

N/A

Worsening Of Chronic Conditions

Yes

No

N/A

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CITY HEIGHTS DENTAL

LOCATE US

600 Burnhamthorpe Rd. W., Suite 1A
Mississauga, ON
L5B 2C4

905 272 3575

info@cityheightsdental.com

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