Palermo Village Dental

COVID SCREENING QUESTIONNAIRE

2525 Old Bronte Rd. Suite# 290, Oakville, ON, L6M 4J2      905-815-8888

As per Public Health regulations, mandatory pre-appointment questions are REQUIRED and MUST be filled out NO MORE THAN 24 HOURS before your dental appointment.

Please fill out this questionnaire prior to your arrival (no more than 24 hours) to help everyone stay safe and healthy.

1: Did you receive your final (or second) vaccination dose more than 14 days ago?
        YES       NO       Unknown   

2: Have you tested postive for COVID-19 in the last 10 days or been told that you should be isolating?
        YES       NO   

3: Do you have any of the following symptoms?
  • Fever and/or chills
  • New onset of cough or worsening chronic cough
  • Shortness of Breath
  • Decrease of loss of sense of taste or smell
        YES       NO   
4: If you are 18 years of age or older:
     Do you have unexplained fatigue/lethargy/malaise/muscle aches (myalgia)
        YES       NO   

5: If you are under 18 years of age:
     Do you have nausea/vomiting or diarrhea
        YES       NO   

If you answered NO OR UNKNOWN TO QUESTION 1 ABOVE please answer questions 6 and 7:

6: Have you traveled outside of Canada in the last 14 days?
       YES       NO   
7: Have you had close contact with a confirmed case of COVID-19 WITHOUT wearing approproate PPE?
       YES       NO   
Patient's Name:
   Today's Date:
   

Patient/Parent/Guardian Signature: