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Prevention & Check Ups
Proactive Oral Hygiene Care
Dental Laser
Restoration
3D CEREC Technology
Endodontics Root Canal Treatment
White Filings
Extraction
Wisdom teeth
Inlays/Onlays
Same Day Dental Crown
Replacement
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Dental bridges
Removable partial dentures
Complete dentures
Cosmetic Dentist
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Sleep Apnea
Metcalfe Dental Experience
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Covid-19 Screening
Covid-19 Screening Form
Date / Time
*
Patient Full Name
*
Please read the patient acknowledgement below, and initial or sign in all areas indicated.
Screening Questions
Pre-Screen
Have you had close contact with anyone with acute respiratory illness or traveled outside of Ontario in the past 14 Days?
Yes
No
Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?
Yes
No
Do you have any of the following symptoms: Fever, New Onset Cough, Worsening Chronic Cough, Shortness Of Breath, Sore Throat, Difficulty Swallowing, Decrease Or Loss Of Sense Of Taste Or Smell, Chills, Headaches, Unexplained Fatigue - Malaise - Muscle Aches, Nausea, Vomiting, Diarrhea, Abdominal Pain, Pink Eye, Running Nose, Nasal Congestion Without Other Known Cause?
Yes
No
Are you 70 years of age and experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?
Yes
No
Day Of Appointment
Have you had close contact with anyone with acute respiratory illness or traveled outside of Ontario in the past 14 Days?
Yes
No
Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?
Yes
No
Do you have any of the following symptoms: Fever, New Onset Cough, Worsening Chronic Cough, Shortness Of Breath, Sore Throat, Difficulty Swallowing, Decrease Or Loss Of Sense Of Taste Or Smell, Chills, Headaches, Unexplained Fatigue - Malaise - Muscle Aches, Nausea, Vomiting, Diarrhea, Abdominal Pain, Pink Eye, Running Nose, Nasal Congestion Without Other Known Cause?
Yes
No
Are you 70 years of age and experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?
Yes
No
Patient Acknowledgement
Any "Yes" responses must be discussed with the managing dentist prior to your appointment.
I, (initial) I verify the information I have provided on this form is truthful and complete. I knowingly and willingly consent to have emergency surgical/dental treatment completed during the COVID-19 pandemic.
*
Patient Signature
*
Name
Submit
Meet the Team
Dental Services
Prevention & Check Ups
Proactive Oral Hygiene Care
Dental Laser
Restoration
3D CEREC Technology
Endodontics Root Canal Treatment
White Filings
Extraction
Wisdom teeth
Inlays/Onlays
Same Day Dental Crown
Replacement
Dental implants
Dental bridges
Removable partial dentures
Complete dentures
Cosmetic Dentist
Smile Makeovers
Teeth Whitening
Porcelain Veneers
Cosmetic Bonding
Invisalign® Dentist
TMD
Sedation
Sleep Apnea
Metcalfe Dental Experience
613-237-7177
Book An Appointment
