Essence Dental Covid-19 Health Declaration

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

  • Fever and/or chills

  • Coughing or barking cough

  • Shortness of breath

  • Decrease or loss of sense of taste or smell

  • Muscle aches or joint pain

  • Extreme tiredness

  • Sore throat

  • Runny or stuffy/congested nose

  • Headache

  • Nausea, vomiting and/or diarrhea

  • - You live with someone who is currently isolating because of a positive COVID-19 test

  • - You live with someone who is currently isolating because of COVID-19 symptoms

  • - You live with someone who is isolating while waiting for COVID-19 test results

If you cannot submit this form, please call the office directly.

905-503-8686

Check the box if the answer is NO