Covid-19 Pre-Screening | essencedental

Essence Dental Covid-19 Health Declaration

How are you feeling today? Please complete this form no more than 48 hours before your scheduled appointment.

First Name

Last Name

I have not tested positive for COVID-19 in the past 10 days or have been told to self isolate

I do not have any of the following symptoms:

Fever and/or chills
New onset of cough / Worsening chronic cough
Shortness of breath
Decrease or loss of sense of taste or smell
If adult > 18 years of age : unexplained fatigue / lethargy / malaise / muscle aches (myalgia)
If child < 18 years of age : nausea/vomiting, diarrhea

I have not travelled outside of Ontario in the last 14 days and/or I have been fully vaccinated for 14 days.

I have not had close contact with a confirmed case of Covid-19 without wearing appropriate PPE and/or I have been fully vaccinated for 14 days.

Initials

Date

905-503-8686