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 travelled outside of Ontario in the last 14 days.

I have not tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE.

I do not have any of the following symptoms, all without another known cause:

Fever
New onset of cough / Worsening chronic cough
Shortness of breath / Difficulty breathing
Sore throat / Difficulty swallowing
Decrease or loss of sense of taste or smell
Chills, headache, unexplained fatigue
Nausea, vomiting, diarrhea, abdominal pain
Muscle aches
Pink eye (conjunctivitis)
Runny nose / Nasal congestion

I am not 70 years of age or older. If you are 70 years or older, you are not experiencing the following symptoms : delirium, unexplained or more falls, acute functional decline or worsening or chronic conditions.

I declare that the information I’ve provided is accurate & complete

Initials

Date

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

905-503-8686