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Home
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About
Services
Cosmetic Dentistry
Family Dentistry
Root Canal Therapy
Dental Implants
Invisalign Clear Braces
Traditional Dental Braces
Dentures
Teeth Whitening
COVID-19 Form
First Visit
Specials
Reviews
Blog
Contact
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COVID-19 Screening Questions
Patient Information
Salutation
Please Select
Mr.
Ms.
Mrs.
Dr.
Name
Date of Birth
Phone Number
Email Address
Do you have any of the following new or worsening symptoms or signs?
New or worsening cough
Yes
No
Shortness of breath
Yes
No
Sore throat
Yes
No
Runny nose, sneezing or nasal congestion
Yes
No
Hoarse voice
Yes
No
Difficulty swallowing
Yes
No
New smell or taste disorder(s)
Yes
No
Nausea/vomiting, diarrhea, abdominal pain
Yes
No
Unexplained fatigue/malaise
Yes
No
Chills
Yes
No
Headache
Yes
No
Have you traveled outside of Canada or had close contact with anyone that has traveled outside of Canada in the past 14 days?
Yes
No
Do you have a fever?
Yes
No
Have you had close contact with anyone with respiratory illness or a confirmed or probable case of COVID-19?
Yes
No
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reception@dvpdentalclinic.ca
