Intake screener effective june 2020 - World Drive Dentistry

page-template-default,page,page-id-1457,page-child,parent-pageid-1061,bridge-core-1.0.4,ajax_fade,page_not_loaded,,qode_grid_1300,footer_responsive_adv,qode-theme-ver-18.0.9,qode-theme-bridge,qode_header_in_grid,wpb-js-composer js-comp-ver-5.7,vc_responsive

Intake screener effective june 2020

COVID 19 INTAKE SCREENING FORM EFFECTIVE JUNE 2020

PLEASE CHECK IF ANY APPLY TO YOU

HAVE YOU OR ANY ONE IN YOUR FAMILY TESTED POSITIVE FOR THE CORONA VIRUS
HAVE YOU OR ANYONE IN YOUR FAMILY BEEN EXPERIENCING SYMPTOMS COMMONLY ASSOCIATED WITH COVID 19 SUCH AS FEVER CHILLS,COUGH COLD OR DIFFICULTY IN BREATHING,LOSS OF TASTE ,SMELL
HAVE YOU OR A MEMBER OF YOUR FAMILY TRAVELLED TO OR FROM OUTSIDE OF CANADA IN THE PAST 14 DAYS
HAVE YOU ANY MEDICAL CONDITION THAT YOU KNOW OF WHICH YOU WOULD LIKE US TO BE AWARE OFF
HAVE YOU HAD CONTACT WITH A KNOWN /SUSPECTED COVID 19 POSITIVE PERSON

THE INFORMATION YOU PROVIDE HELPS MAKE IT SAFE FOR US ALL

I CERTIFY THAT THE INFORMATION PROVIDED IS TRUTHFUL AND CORRECT
I WILL INFORM THIS OFFICE IF THERE IS ANY CHANGE IN THE INFORMATION SUPPLIED IN THE NEXT 14 DAYS
INITIALS
MY INITIALS MAY PLEASE BE TREATED AS MY SIGNATURE ABOVE

Name *

First

Last

Email *

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date / Time

Date

Time

Email *

Comment

905-696-7500

70 World Drive

Intake screener effective june 2020

Visit Us

Contact Us

Dental Services

Patient Services

Information