COVID-19 Screening Form

Thank you for scheduling your appointment with ADL Dental Labs. 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
First Name:
Last Name:
SYMPTOMS:


YesNo
Have you had a fever greater than 37.5 C in the past 14 days?
YesNo
Do you have a cough, sore throat, shortness of breath, or difficulty breathing in the last 7 days?
YesNo
Do you have any FLU-LIKE SYMPTOMS? (Chills, fatigue, Muscle pain or headaches.)
YesNo
Pink eye, runny nose
YesNo
Do you have any loss of your senses of taste or smell?
YesNo
Had you tested positive for COVID-19?
YesNo
In the past 14 days, has you been in CONTACT with anyone that is showing any symptoms of COVID-19 or has been diagnosed with COVID-19?
YesNo
IN the last 30 days, had you been outside of Canada?
YesNo
If outside of canada, had you completed the mandatory 14-days self-isolation?
YesNo
Has anybody in your household been in close contact with a confirmed Covid case?
YesNo
If yes.
Have they been tested for COVID and are waiting for their results?
SIGNATURE OF PATIENT
Printed Name
Date
(YYYY-MM-DD)