COVID-19 Screening and APPOINTMENT INFORMATION

PLEASE FILL THIS FORM OUT THE DAY OF YOUR APPOINTMENT PRIOR TO COMING INTO THE OFFICE AND NOT BEFORE.

PLEASE ENSURE YOU WEAR A MASK or FACE COVERING WHEN ENTERING THE OFFICE.

NOTE: ONLY THE PERSON WITH THE BOOKED APPOINTMENT IS ALLOWED IN THE OFFICE and ONLY ONE PARENT OR GUARDIAN WITH A CHILD WITH BOOKED APPOINTMENT UNDER 18.

Covid 19 Screening Form
Have you ever been diagnosed with COVID-19?
Do you have any of the following symptoms: fever, new or existing cough, breathing difficulty?
Have you traveled internationally within the last 14 days (outside Canada)?
Have you had close contact with a person with acute respiratory illness who has been outside Canada in the last 14 days?
Do you have any of the following symptoms? Please check any that apply, if none apply please check "None of the above."
Patients 70 years of age or older: Are you experiencing any of the following symptoms?

I, THE UNDERSIGNED, CERTIFY THAT I HAVE FILLED OUT THE FORM ACCURATELY AND HAVE NOT KNOWINGLY OMITTED ANY INFORMATION.

Signature

Dr. Elizabeth Dimovski Dental

2 Philosopher's Trail, Unit 1

Brampton Ontario L6S 4C9

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Brampton Dental Office | Dentists in Brampton Ontario