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

Has a doctor, health care provider or public health unit told you that you should currently be isolating (staying at home)?

In the last 14 days have you been directed by a border agent to comply with federal quarantine requirements due to international travel?

In the last 5 days (if fully vaccinated) / 10 days (if vaccinated or immunocompromised) have you experienced any of these symptoms?

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

Do any of the following apply?

- 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

In the last 5 days (if fully vaccinated / 10 days (if vaccinated or immunocompromised) have you tested positive on a rapid antigen test, molecular test, or home-based self-testing kit?

Initials

Date

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

905-503-8686

Check the box if the answer is NO