Pre-Screening Form - Maple Street Dental : Maple Street Dental

Name*

First Last

Email*

Appointment Date and Time*

Please answer the following questions

Do you have TWO (2) of the following symptoms that are not related to a known pre-existing condition:*

A fever anytime in the last two weeks? Cough? Sore throat?
Runny nose? Diarrhea? Headache? Loss of smell/taste?
Fatigue/exhaustion? Muscle pain?
Children: Any purple markings on fingers/toes?

Yes
No

Have you been advised by Public Health, a health care provider or a peace officer that you are currently required to self-isolate?*

Yes
No

Are you waiting for a Covid-19 test or Covid-19 test results AND have been told to self-isolate?*

Yes
No

Have you travelled outside of the province within the last 14 days? (unless exempt from self-isolation)?*

Yes
No

Has an individual in your household returned from outside of the province in the past 14 days for any reason, and now someone within the household has developed one or more symptoms of Covid-19 as listed above?*

Yes
No

Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes, or auto-immune disorder?*

Yes
No

Consent

I confirm I have answered these questions truthfully and to the best of my ability.