South London Dental Care Centre
COVID-19 Pre Screening Form
324 Adelaide Street South, London, Ontario, N5Z 3L2
519-672-8770
First Name:
Last Name:
Date Completed:
Staff Screener:
In Office Temperature:
Screening Questions
Pre-Screen
Yes
No
Have you travelled outside of Canada in the past 14 days?
Have you tested positive to COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
Do you have any of the following symptoms:
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
Headaches
Unexplained fatigue/malaise/muscle aches (myalgias)
Nausea/vomiting, diarrhea, abdominal pain
Pink eye (conjunctivitis)
Runny nose/nasal congestion without other known cause
If you are 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?
I verify that the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to having my dental treatment completed during the COVID-19 pandemic.
I will notify South London Dental Care Centre should I develop any of the above symptoms prior to my scheduled appointment.
Patient/Parent/Guardian Signature:
Clear
