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COVID-19 Health Questionnaire Consent Form

200 – 5063, North Service Rd, Burlington, ON L7L 5H6      905-465-2476

In order to reduce the risk of spreading COVID-19, we are asking some screening questions below.

Please bring your own personal mask. If accompanying your child, please bring your own personal mask and face shield. Children older than 2 years old also require their own personal mask. You will be asked to use hand sanitizer often while in the office. Please use our dedicated screening text line 647-323-KIDS (5437) upon arrival to the parking lot. We will let you know when you able to enter the office. Thank you for your patience and cooperation.

Personal Information

Patient's Name:
Patient's Birth Date:

Screening Questions

Indicate which of the following conditions apply to you presently or in the past.

Pre-Screen
Yes No
Have you, your child, or others in your household or accompanying you to today’s appointment or other recent acquaintances tested positive for or been diagnosed as having COVID-19?

If yes, when?
Have you, your child, or others in your household or accompanying you to today’s appointment travelled outside of Ontario in the past 14 days?
Do you, your child, or others in your household or accompanying you to today’s appointment or other recent acquaintances have:
  • A fever, or have felt feverish (defined as above 100.4 degrees° F or 38 degrees ° C)
  • New onset cough
  • Worsening chronic cough
  • Shortness of breath
  • Difficulty breathing
  • Sore throat
  • Difficulty swallowing
  • Decrease or loss of sense of taste or smell
  • Chills
  • Headaches
  • Unexplained fatigue/malaise/muscle aches
  • Nausea/vomiting, diarrhea, abdominal pain
  • Pink eye (conjunctivitis)
  • Runny nose/nasal congestion without other known cause
  • Discoloring of toes and or/fingers

I understand that if the answers to any of these questions is yes, I will be asked to reschedule today’s appointment. If you or your child start feeling ill with any symptoms of COVID-19 within 14 days of your appointment, please call the office immediately.

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Thank you for your continued trust in our practice. Please be assured that, as a matter of routine office protocol, the dentist and staff members of The Children’s Dental Centre have always strictly followed provincial and federal regulations and guidelines relating to infection control protocols established for limiting transmission risk of potentially communicable diseases in our dental clinic. We will of course continue to do so with an even heightened attention to detail in light of the current pandemic environment. As is the case with transmission of most all contagious illnesses, such as a common cold or seasonal flu, you and/or your child may have recently been exposed to a virus called novel SARS-CoV-2 that can cause a disease known as COVID-19. Social Distancing nationwide has shown to be effective in reducing the transmission of novel degrees, and although we have taken measures to provide for social distancing (6 feet) in our practice, due to the nature of the procedure we provide, it is not possible to maintain ideal social distancing between the patient, the parents or caregivers of the patients, dentist, staff and/or other patients and their parents or caregivers at all times.

Patient/Parent/Guardian Signature: