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.

Have you ever been diagnosed with COVID-19?

YES

Do you have any of the following symptoms: fever, new or existing cough, breathing difficulty?

YES

Have you traveled internationally within the last 14 days (outside Canada)?

YES

Have you had close contact with a person with acute respiratory illness who has been outside Canada in the last 14 days?

YES

Do you have any of the following symptoms? Please check any that apply, if none apply please check "None of the above."

Fever

Difficulty breathing

Pink eye (conjunctivitis)

Chills

New onset of cough

Sore throat

Headaches

Runny nose/nasal congestion without other known cause

Worsening chronic cough

Difficulty swallowing

Unexplained fatigue/malaise/muscle aches (myalgias)

Shortness of breath

Decrease or loss of sense of taste or smell

Nausea/vomiting, diarrhea, abdominal pain

None of the above

Patients 70 years of age or older: Are you experiencing any of the following symptoms?

Delirium

Unexplained or increased number of falls

Acute functional decline

Worsening of chronic conditions

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

PATIENT

PARENT

GUARDIAN

Signature

Thanks for submitting!

Dr. Elizabeth Dimovski Dental

2 Philosopher's Trail, Unit 1

Brampton Ontario L6S 4C9

Phone:905-458-6620

fax: 905-458-7085

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