South Kent Dental
COVID-19 Patient Pre-Screening Form
Primary Phone Number
Alternate Phone Number
Please answer the following questions:
Have you travelled outside of Canada in the last 14 days?
Have you tested positive for COVID-19?
Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
Are you experiencing any of the following symptoms?
New onset of cough
Worsening chronic cough
Shortness of breath
Decrease or loss of sense of taste or smell
Unexplained fatigue/malaise/muscle aches
Nausea/vomiting, diarrhea, abdominal pain
Pink eye (conjunctivitis)
Runny nose or nasal congestion without other know cause
Are you 70 years of age or older?
If you are 70 years of age or older, please indicate if you are experiencing any of the following symptoms.
Unexplained or increased number of falls
Worsening of chronic conditions
Acute functional decline
Explain any YES answers in the box below:
Signature: By typing your name in the box below, you acknowledge that your answers you provided are true and accurate to the best of your knowledge:
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