COVID-19 Patient Screening

Please answer the following questions to ensure you are COVID-19 symptom free.

Patient Name *

Patient Age *

1. Have you tested positive for COVID-19 in the past month or have been advised by your physician or local public health department to self-isolate?

Yes

2. Do you have or recently have had (within 10-14 days) any of the following symptoms:

Fever (above 37.8-38.0 degrees Celsius) or feeling hot, chills/feverish *

Yes

Shortness of breath or other difficulties breathing *

Yes

Cough or recent worsening of a chronic cough *

Yes

Flu-like symptoms such as stomach upset, diarrhea, headache, fatigue or sore throat, without another known cause *

Yes

Recent alteration or loss of taste or smell *

Yes

Any new, unusual symptoms, e.g., feeling unwell, or sudden onset of runny nose, pink eye (conjunctivitis) *

Yes

3. Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19 without wearing appropriate PPE? (Healthcare workers who have worn appropriate PPE may answer No) *

Yes

4. Have you travelled in the past 14 days out of the country or to any COVID-19 hot spots? *

Yes

5. In the past 14 days, have you been to any large gatherings where social distancing was not observed? *

Yes

6. Do you have heart, lung or kidney disease, diabetes, or any auto-immune conditions? *

Yes

Spam Blocker

At Family Dental Care in Prince George, our passion is oral health. Our dentists, specialists and dental team are committed to helping you maintain your smile and your overall health.
- The Family Dental Care Team

COVID-19 Patient Screening

New Patients Always Welcome